FEHB Plans for USPS Career Employees

Guide to Federal Employees Health Benefits Plans For United States Postal Service Employees Belated open season elections accepted until 5:00 PM Central Time December 29, 2003. Center for Retirement and Insurance Service Visit OPM’s web site at www.opm.gov/insure RI 70 -2 Revised November 2003 Dear Federal Employees Health Benefits Program Participant: It is hard to believe that a year has passed and the Federal Employees Health Benefits (FEHB) Open Season is here again. This is your annual opportunity to evaluate your personal needs and, if necessary, change health plans. I am pleased to present the 2004 FEHB Guide to help you with your evaluation. It takes a lot of information to help a consumer make wise healthcare decisions. The information in this Guide and our web-based resources make it easier than ever to get information about premiums, to compare benefits, to read customer service satisfaction ratings for the national and local plans that may be of interest, and to learn about quality information from the National Committee for Quality Assurance, the Joint Commission on Accreditation of Healthcare Organizations, and URAC. The FEHB Program continues to be an enviable national model that offers exceptional choice, and uses private-sector competition to keep costs reasonable, ensure high-quality care, and spur innovation. The Program, which began in 1960, is sound and has stood the test of time. It enjoys one of the highest levels of customer satisfaction of any healthcare program in the country. President Bush has chosen the FEHB as a model for modernizing and improving Medicare. I continue to take aggressive steps to keep the FEHB Program on the cutting edge of employersponsored health benefits. We demand cost-effective quality care from our FEHB carriers and we have encouraged Federal agencies and departments to pay the full FEHB health benefit premium for their employees called to active duty in the Reserve and National Guard so they can continue FEHB coverage for themselves and their families. Our carriers have also responded to my request to help our members to be prepared by making additional supplies of medications available for emergencies as well as call-up situations and you can help by getting an Emergency Preparedness Guide at www.opm.gov. OPM’s HealthierFeds campaign is another way the carriers are working with us to ensure Federal employees and retirees are informed on healthy living and best-treatment strategies. You can help to contain healthcare costs and keep premiums down by living a healthy life style. Open Season is your opportunity to review your choices and to become a better educated consumer to meet your healthcare needs. Use this Guide, the health plan brochures, and the web resources at www.opm.gov/insure to make your choice an informed one. Finally, if you know someone interested in Federal employment, refer them to www.usajobs.opm.gov. Sincerely, Kay Coles James Director Table of Contents Page: FEHB and PostalEASE .......................................................................................................................................... 1 FEHB and You .......................................................................................................................................................... 2 Pre-tax Payment of Premium Contributions .................................................................................................. 5 Program Features ................................................................................................................................................ 8 Picking a Health Plan .......................................................................................................................................... 9 Preventing Medical Mistakes .......................................................................................................................... 12 FEHB Web Resources ........................................................................................................................................ 13 Stop Health Care Fraud ...................................................................................................................................... 14 Federal Employees Receiving Premium Conversion Tax Benefits Table of Permissible Changes .......................................................................................................................... 15 FEHB PostalEASE Worksheet ............................................................................................................................ 20 Plan Comparisons Nationwide Fee-For-Service Plans and Consumer-Driven Plans Open to All .................................... 26 Nationwide Fee-For-Service Plans Open Only to Specific Groups ...................................................... 32 Health Maintenance Organization Plans, Plans Offering a Point of Service Product and Consumer-Driven Plans .................................................................................................................... 36 Things to Remember ✔ ■ The plan you choose can make a difference in your health. ✔ ■ Be aware of benefit changes for 2004. ✔ ■ Check the premium for 2004. The information in this Guide gives you an overview of the FEHB Program and its participating plans. Read the plan brochures before you make any final decisions about health plans. i Federal Employees Health Benefits Open Season November 10 to 5:00 PM Central Time December 9, 2003 Belated open season elections accepted until 5:00 PM Central Time December 29, 2003. Because of a delay in mailing the 2004 Guide to Federal Employees Health Benefits Plans, BELATED OPEN SEASON ELECTIONS WILL BE ACCEPTED UNTIL 5:00 PM CENTRAL TIME ON DECEMBER 29, 2003. If you have any trouble using or do not wish to use the PostalEASE telephone, intranet or self-service kiosk, or if you are unable to use the telephone because you are deaf or hard of hearing, or if you cannot use the telephone, intranet or employee self-service kiosk for medical reasons, you may contact your local personnel office for assistance. Please complete the PostalEASE health benefits worksheet first. You may still use the standard form (SF) 2809 Health Benefits Election Form instead of the PostalEASE health benefits worksheet. However, SF2809 has not been updated by the Office of Personnel Management to capture certain new data that is sent to health plans, which is why the PostalEASE health benefits worksheet is the better choice if you cannot use the telephone or employee web. Open season and belated open season enrollment changes and new enrollments made by 5:00 PM Central Time on December 29, 2003, will be effective January 10, 2004 (Pay Period 03-04). New premium payments will be reflected in the paycheck dated January 30, 2004. ii FEHB and PostalEASE B eginning with the November 2003 open season, employees will make their Federal Employees Health Benefits (FEHB) program choices through the PostalEASE system. By using PostalEASE for health benefits, and by sending information to health insurance companies electronically instead of via paper forms as in past open seasons, the Postal Service expects that employees who make health benefits changes will get their new insurance cards more quickly. All the information you need for using PostalEASE is included in the FEHB PostalEASE Worksheet found on pages 20 to 23 of this Guide. Just follow the instructions to: • Enroll • Change Enrollment • Cancel Enrollment • Review or change your pending open season transaction • Review or update your dependent information • Review your current enrollment information • Receive a copy of a health benefits election that was processed using PostalEASE If you want to make a change for the 2004 plan year, you may do so during the annual FEHB Open Season, which is from November 10 through December 9, 5:00 PM Central Time. If you currently have an FEHB enrollment and you do not want to make any changes, do nothing. Your coverage will continue automatically. All open season Self Only enrollments, changes to Self Only coverage, and cancellations, should be entered as employee “self service” transactions using PostalEASE. Since dependent information is not required, such transactions are simple. Most Self and Family enrollments can also be completed as employee self service transactions, although they require additional information. The easiest way to do this is via the PostalEASE Employee Web, which is available through the Blue page or on a kiosk. Many Self and Family transactions can also be completed by telephone. If you are unable to enter your dependent information via the telephone, the PostalEASE system will refer you to the Web, a kiosk, or your local personnel office. PostalEASE provides the enrollment date, processing date, and effective date when you complete your transaction. You may delete or change a pending transaction until it is processed. This Guide contains important FEHB policy information that used to be provided to you as part of the SF 2809 Health Benefits Election Form. Be sure you understand how your health benefits work, including information on which family members are eligible, how you pay for your health benefits premiums using pre-tax dollars, and the limitations on making a health benefits change outside of open season. As a reminder, to continue health benefits coverage during retirement, you must have had five consecutive years of FEHB coverage immediately prior to your retirement. If you need help understanding any of this information, or you need help using PostalEASE, you should contact your local personnel office for assistance. If you are newly eligible for FEHB as a career employee, you may also use PostalEASE during the first 60 days after your date of appointment. Please do not wait until late in the open season to enter your choice via PostalEASE. If you select Self and Family coverage, then you’ll need to enter information about your dependents. Although this will take extra time, providing this information is required under FEHB regulations. Just complete the FEHB PostalEASE Worksheet and follow the instructions carefully. 1 FEHB and You Overview The United States Postal Service (USPS) provides health benefits to its career employees by participating in the Federal Employees Health Benefits (FEHB) Program, which is administered by the U.S. Office of Personnel Management (OPM), Office of Retirement and Insurance Services. FEHB began operation in July 1960 and almost 8l5 million people are in the program, including 2.2 million federal and postal employees, 1.85 million retirees, and eligible family members. It is the largest employer-sponsored health insurance program in the world. OPM interprets health insurance laws and writes regulations for the FEHB Program. It gives advice and guidance to the USPS and other participating agencies to process your enrollment changes and to deduct your premiums. OPM also contracts with and monitors all of the plans participating in the FEHB Program. The purpose of this 2004 Guide to Federal Employees Health Benefits (FEHB) Plans is to provide information about enrollment and premium features that USPS career employees must consider when selecting a health insurance plan under the FEHB Program. The Guide is a summary of FEHB plans – the plan brochures give specific benefit information. You can get individual plan brochures directly from the health plans, from your local personnel office, or from the OPM web site www.opm.gov/insure which also has a copy of this guide in addition to various health plan brochures and helpful information. You may choose from among Fee-for-Service (FFS) plans regardless of where you live (see pages 25 through 34) and from Health Maintenance Organizations (HMO’s) plans if you live (or sometimes if you work) within the area serviced by the plan (see pages 35 through 65). Some HMOs also offer a Point of Service (POS) product which allows you to use providers who are not part of the HMO network, but at an increased cost. While FEHB eligibility, enrollment requirements and the plans available for 2004 are the same for federal and USPS employees alike, the Postal Service pays a higher percentage contribution towards career postal employee premium rates than the rest of the federal government. All employee premium rates are calculated using the “Fair Share Formula.” Coverage New Employees – New employees have the opportunity to select a health plan with 60 days of being hired. Current Employees – Current employees have an opportunity to select or change plans: • During Open Season • When certain life events occur (see table on pages 16 through 19 of this Guide) NOTE: These elections MUST be made within certain time limits as specified in the table. Your choice of plans and options includes Self Only coverage just for you, or Self and Family coverage for you, your spouse, and unmarried dependent children under age 22 (and in some cases, a disabled child 22 years or older who is incapable of self-support). Eligible Family Members – Eligible family members for “self and family” health benefits registration purposes include an enrollee’s: • Spouse • Unmarried dependent children under age 22, including legally adopted children and recognized natural (born out-of-wedlock) children. • Unmarried dependent stepchildren and foster children, (including foster children who are also your grandchildren) under age 22 if they live with the enrollee in a regular parent-child relationship. • Unmarried dependent children age 22 or over who are incapable of self-support because of physical or mental incapacity that existed before their 22nd birthday. 2 FEHB and You Ineligible Members – Even though the following family members may live with and/or be dependent upon the enrollee, they are NOT ELIGIBLE for coverage under the enrollee’s “self and family” FEHB program enrollment: • Parents and other relatives • Former spouses. Loss of Coverage – When an event occurs that causes you or your family member to lose coverage, the FEHB Program offers a continuation of coverage feature, either temporarily or by permanent conversion to a private sector policy. Such events include but are not limited to: • Child reaching age 22 • Separation • Retirement • Divorce • Death • Relocation • LWOP Status* * Leave Without Pay Status – FEHB Program regulations state that you may continue your FEHB coverage for up to 365 days while you are in an LWOP status, provided that you continue to pay the employee share of the premium. The Postal Service will invoice you for your share of the premium unless you complete and submit to your personnel office PS Form 3111, FEHB Coverage or Termination While In Leave Without Pay (LWOP) Status, to terminate coverage. At 365 days in LWOP status, your FEHB coverage terminates. It is your responsibility to report life events that may cause you or your family member to lose eligibility. It is also your responsibility to complete and submit any required paperwork to change your enrollment and/or apply for any continuation of coverage, if eligible, within 60 days of loss of coverage. If you have questions, see your local personnel office. If you lose coverage under the FEHB Program, you should automatically receive a Certificate of Group Health Plan Coverage from the last FEHB Plan to cover you. If not, the plan must give you one on request. This certificate may be important to qualify for benefits if you join a non-FEHB plan. FEHB Open Season Each year you have the opportunity to enroll or change enrollment during an open season. The 2003 Open Season is from November 10 through December 9 at 5:00 p.m. Central Time. Employees may make any one – or a combination – of the following changes: • Enroll if not enrolled • Change from one plan to another • Change from one option to another • Change from Self Only to Self and Family • Change from Self and Family to Self Only • Change from pre-tax to post tax premium deductions or vice versa (see pages 5 through 7 of this Guide) • Cancel enrollment If you decide to do any of the above actions, you MUST follow the instructions on the FEHB Worksheet contained in the center of this Guide and enter your election in PostalEASE via the Web, kiosk, or phone or submit to your local personnel office by 5:00 p.m. Central Time on December 9, 2003. It is critical that this be done timely. 3 FEHB and You Your new enrollment or any changes that you make to your existing coverage will take effect on January 10, 2004 and the change in premium rate deductions will be seen in your January 30, 2004 earnings statement. If you decide NOT to change your enrollment, DO NOTHING, and your present enrollment will continue automatically unless your plan is not participating in 2004. If your plane is not participating in 2004 you MUST choose another plan during open season or you will not have FEHB coverage. Ask your local personnel office for a list of the plans that will terminate at the end of the 2003 plan year. If you decide to cancel your coverage during open season, you must cancel it using PostalEASE which includes a confirmation by you that you clearly accept the consequences of canceling. The cancellation will become effective on January 9, 2004. If you pay premium contributions on a pre-tax basis (which most career employees do) you will not be able to cancel or reduce (change from Self and Family to Self Only) coverage outside of Open Season unless you experience a qualified life status change and your election is in keeping with the change. See pages 5 through 7 of this Guide on Pre-tax Payment of Premium Contributions and the OPM table of permissible changes pages 16 through 19 of this Guide. Note to those considering retirement: To be eligible to carry your FEHB enrollment into retirement, you must have been continuously covered, either as an enrollee or as an eligible family member under another FEHB enrollment, for the 5 years immediately preceding retirement, or if less than 5 years, for the entire period since your first opportunity to enroll. You, as an employee, are responsible for being informed about your health benefits. You should thoroughly read this Guide, the brochures of plans that interest you, and the bulletin board notices on health benefits topics. These include family member eligibility, the option to continue or terminate an enrollment during periods of non-pay status or insufficient pay, dual enrollment prohibition, coverage for former spouses, and discontinued health insurance plans. Be sure to read the section on the pre-tax payment of health insurance premium contributions, which specifies Internal Revenue Service (IRS) restrictions for reducing or canceling coverage (see pages 5 through 7 of this Guide). After referring to these sources, if you still have questions regarding eligibility, enrollment criteria, and continued coverage after certain life events, or if you need assistance making your choice in PostalEASE, contact your local personnel office. NOTE: Falsifying or misrepresenting family member eligibility or enrollment is a violation of federal law and may subject an employee to fine, imprisonment and/or disciplinary action. 4 Pre-Tax Payment of Premium Contributions T he Postal Service has established the pre-tax payment of health insurance premium contributions as a tax-saving benefit feature for its employees. This feature has been sponsored by the Postal Service since 1994. Payment of premiums on a pre-tax basis prohibits enrollees from reducing coverage unless they qualify as described in the section “Reducing Coverage” below. Social Security Administration. (Your Medicare, life insurance, retirement plan, and Thrift Savings Plan benefits are not affected.) Second, there are some restrictions on reducing or canceling your coverage outside FEHB Open Season that apply if you pay your premium contributions with pre-tax money. These are explained in the section “Reducing Coverage” below. Most employees prefer paying their premiums with pre-tax money because they save on taxes. Nevertheless, if for any reason you do not want this method of payment, and instead wish to have premiums paid with after-tax money, you must submit a form that is available from your local personnel office to waive the pre-tax treatment. For more information, see the section “How to Waive or Restore Pre-Tax Payment” on page 7 of this Guide. Pre-Tax Withholding If you are a career employee, your premium contributions will automatically be withheld from pay as “pre-tax money”, which means the premium amount is not subject to income, Social Security, or Medicare taxes. Premiums are collected on a pre-tax basis automatically, unless you waive this treatment. Once you begin to pay FEHB premiums with pre-tax money, this method continues each year. Although you are automatically enrolled to pay premium contributions with pre-tax money, you do have an opportunity during FEHB Open Season, or if you have a qualified life status change, to waive this treatment and pay your premiums with “aftertax money”. This means you give up the tax savings of paying with pre-tax money. There are two possible disadvantages of paying your premiums with pre-tax money that you should balance against the tax savings you receive. First, when you retire, if you begin to collect Social Security (normally this occurs at age 62 at the earliest), you may receive a slightly lower Social Security benefit. Paying your FEHB premiums with pretax money reduces the earnings reported to the Reducing Coverage When your premium contributions are withheld on a pre-tax basis, certain Internal Revenue Service (IRS) guidelines affect your ability to change coverage. You may elect to reduce your coverage, that is, to cancel your FEHB enrollment, or to go from Self and Family to Self Only coverage, only during an FEHB Open Season, unless you have a qualified life status change. These are shown in the chart on pages 16 to 19 of this Guide titled “USPS Employees: Table of Permissible Changes in FEHB Enrollment and Pre-Tax/After-Tax Premium Payment.” Refer to the column labeled “FEHB Enrollment Change That May Be Permitted” and the header 5 Pre-Tax Payment of Premium Contributions “Cancel or Change to Self Only.” You also must satisfy the time limits shown in the column labeled “Time Limits in Which Change May Be Permitted.” If you are the only person left in your Self and Family enrollment as a result of a qualified life status change in marital or family status, you must elect to reduce the enrollment (elect Self Only coverage or cancel coverage) by submitting the FEHB PostalEASE Worksheet to your local personnel office within the time limit shown in the column labeled “Time Limits in Which Change May Be Permitted” in the chart on pages 16 to 19 of this Guide. Otherwise, your self and family enrollment will continue until another event (that is, a qualified life status change or FEHB Open Season) occurs that allows you to elect to reduce coverage. The election cannot become effective retroactively, therefore, there will be no retroactive premium adjustment. Reducing your FEHB coverage outside of FEHB Open Season must be in keeping with, or on account of, your qualified life status change. For example, if you have a new baby, you usually would not change from Self and Family to a Self Only enrollment, or cancel coverage. A qualified life status change does not allow you the opportunity to change plans or options, only to reduce (from Self and Family to Self Only) or cancel your current plan within the time limit shown in the column labeled “Time Limits in Which Change May Be Permitted” in the chart on pages 16 to 19 of this Guide. To reduce your FEHB coverage outside of FEHB Open Season, submit an FEHB PostalEASE Worksheet to your local personnel office within the time limits shown in the column labeled “Time Limits in Which Change May be Permitted” in the table on pages 16 to 19 of this Guide. You must provide any supporting documentation requested by your local personnel office. The effective date of a change from Self and Family to Self Only will be the first day of the pay period that follows the pay period in which your Worksheet is received by your personnel office. The effective date of a cancellation will be the last day of the pay period in which your Worksheet is received by your personnel office, if received within the specified time limits. It is your responsibility to timely notify and submit necessary forms to your local personnel office when you are the only person left on your enrollment. Retirement is NOT a qualified life status change that allows cancellation prior to the date of your retirement. If you wish to cancel an enrollment at retirement, your personnel office will accept your completed SF 2809 and forward it to OPM for processing after separation from the Postal Service. (Annuitants’ FEHB premium contributions are not withheld as a pre-tax payment, thus once you are an annuitant, reduction in coverage is allowed at any time.) During periods of non-pay status or insufficient pay, you may terminate your FEHB enrollment. The effective date of termination is retroactive to the end of the last pay period in which a premium contribution was withheld from pay. Contact your local personnel office for more information about how termination during periods of non-pay status or insufficient pay affects FEHB enrollment. 6 Pre-Tax Payment of Premium Contributions How to Waive or Restore Pre-Tax Payments If you pay premiums with after-tax money, you will not be affected by the IRS guidelines described above that restrict reductions in coverage. You may reduce your level of FEHB coverage at any time of year without having a qualified life status change. You will give up the tax savings from paying your premium contributions with pre-tax money. If you wish to pay your premiums with after-tax money, you must contact your local personnel office and ask for Postal Service (PS) Form 8201, Pre-tax Health Insurance Premium Waiver/ Restoration Form. During Open Season, complete the form and return it to your local personnel office by 5:00 p.m. Central Time, December 9, 2003. If this is your initial opportunity to enroll in FEHB, you have 60 days to submit your election to your local personnel office. You also may make such an election when you have a qualified life status change which is shown in the chart on pages 16 to 19 of this Guide. Refer to the column labeled “Premium Conversion Election Change That May Be Permitted.” You must also satisfy the time limits shown in the column labeled “Time Limits in Which Change May Be Permitted.” If you submit a waiver, your premiums will continue to be paid with after-tax money in future years, unless you later submit another PS 8201 to restore pre-tax payment of FEHB premiums. If you previously submitted a waiver in order to pay with after-tax money, and you want to begin paying your premiums with pre-tax money, you may submit PS 8201 to restore pre-tax payment of your premium contributions. You may change the method of payment from pre-tax to after-tax, or the reverse only during the annual FEHB Open Season or following a qualified life status change and within the time limits described earlier in this section. Your Right To More Information This section of the FEHB Guide serves as your summary plan description of the USPS Plan for the Pre-tax Payment of Health Insurance Premiums. There is also a legal plan document containing the full legal plan provisions, which you may arrange to view by writing to: PRETAX PAYMENT OF HEALTH INSURANCE PREMIUMS PLAN ADMINISTRATOR 475 L’ENFANT PLAZA SW ROOM 9670 WASHINGTON DC 20260-4210 7 Program Features • No Waiting Periods. You can use your benefits as soon as your coverage becomes effective. There are no pre-existing condition limitations even if you change plans. • A Choice of Coverage. Choose between Self Only or Self and Family. • A Choice of Plans and Options. Select from Fee-For-Service (with the option of a Preferred Provider Organization), Health Maintenance Organization, Point of Service plans, or Consumer-Driven plans. • A Government Contribution. The USPS pays 85 percent of the average premium toward the total cost of your premium, up to a maximum of 88.75 percent of the total premium for any plan. • Salary Deduction. You pay your share of the premium through a payroll deduction and have the choice of doing so using pretax dollars. When your premium contributions are withheld on a pretax basis, certain Internal Revenue Service guidelines affect your ability to change coverage. You may elect to reduce your coverage, that is, to cancel your FEHB enrollment, or to go from Self and Family to Self Only coverage, only during an FEHB Open Season, unless a qualified life status change occurs. See your local personnel office for details. • Annual Enrollment Opportunity. Each year you can enroll or change your health plan enrollment. This year the Open Season runs from November 10, 2003, through December 8, 2003. Other events allow for certain types of changes throughout the year. See your local personnel office for details. • Continued Group Coverage. Eligibility for you or your family members may continue following your retirement, divorce, death, or changes in employment status. See your local personnel office for more information. • Coverage after FEHB Ends. You or your family members may be eligible for temporary continuation of FEHB coverage or for conversion to non-group (private) coverage when FEHB coverage ends. See your local personnel office for more information. • Consumer Protections. Go to www.opm.gov/insure/health/consumers to see your appeal rights to OPM if you and your plan have a dispute over a claim; to read the Patients’ Bill of Rights and the FEHB Program; and to learn about your privacy protections when it comes to your medical information. 8 Picking a Health Plan Step 1: What type of health plan is best for you? You have some basic questions to answer about how you pay for and access medical care. This is because Fee-for-Service (FFS) plans -- with and without a Preferred Provider Organization (PPO) – Health Maintenance Organizations (HMO), Point-of-Service (POS) plans, and Consumer-Driven plans all operate differently. Health Maintenance Organization You generally must use the network; no benefits outside of the network – you pay all costs. Fee-for-Service w/PPO Choice of doctors, hospitals, pharmacies, and other providers You must use the plan’s network for full benefits. Not using PPO providers means only some or none of your benefits will be paid. Referral not required to get full benefits. Fee-for-Service w/o PPO You may use any doctor, hospital, etc. Benefits are not limited by where you get care. Point-of-Service You must use network for full benefits. You may go outside the network but it will cost you more. ConsumerDriven Plans You may use network and non-network providers. Not using the network will cost you more. Specialty care Referral not required to get full benefits. Referral generally required from primary care doctor to get benefits. Your out-ofpocket costs are generally limited to copayments. Referral required to get full benefits. Referral not required to get full benefits. Out-ofpocket costs You pay fewer costs if you use a PPO provider than if you don’t. Some if you don’t use network providers. You pay regular plan out-ofpocket costs. You pay less if you use a network provider than if you don’t. Little if you use the network. You will have to file your own claims if you don’t use the network. You pay less if you use a network provider than if you don’t. Some if you don’t use network providers. Paperwork You have to file your own claims. Little, if any. See Definitions starting on page 7 for a more detailed description of each type of plan. 9 Picking a Health Plan Step 2: What services are important to you and what health care do you expect to use? Refer to your medical and insurance records from last year as a guide to what services you might use this year. Add up the actual costs to you, including premiums. Estimate what you might spend on your health care for deductibles, coinsurance/copayments, and services that are not covered. Are there any annual limits for days or services covered and on the dollar amount the plan will spend on you? What is the maximum you will have to pay out-of-pocket each year? Consult the health plans’ brochures to find this benefit information. Copies of brochures as well as a tool to complete this sheet on-line are on our web site at www.opm.gov/insure/health. Health Plan _____________ Annual premium Office visit to primary care doctor Office visit to specialist Hospital inpatient deductible/copay/ coinsurance Hospital room & board charges Generic drug (local pharmacy) Brand name drug (local pharmacy) Catastrophic protection limit Mental health care visits Home health care visits Durable medical equipment Maternity care Well-child care Routine physicals Accreditation Health Plan _____________ Health Plan _____________ The following information can be found in the Member Survey Results section in the benefit charts. Overall member satisfaction with plan Getting needed care Getting care quickly How well doctors communicate Customer service Claims processing 10 Picking a Health Plan Step 3: Consider quality. Quality is how well health plans keep their members healthy or treat them when they are sick. Good quality doesn’t always mean receiving more care. Good quality health care means doing the right thing at the right time, in the right way, for the right person to achieve the best possible results. We provide two types of quality information in the plan benefit charts: independent evaluations (accreditation) from private organizations and evaluations by enrollees (member survey). NCQA (www.ncqa.org): 1 = Excellent (HMO) or Full (PPO) 2 =Commendable (HMO only) 3 = Accredited (HMO) or One-Year (PPO) 4 = Provisional (HMO and PPO) 6 = New Health Plan JCAHO (www.jcaho.org): 1 = Accreditation with Full Compliance 2 = Accreditation with Requirements for Improvement 3 = Provisional 4 = Conditional URAC (www.urac.org): 1 = Full Accreditation 2 = Conditional Accreditation 3 = Provisional Accreditation Accreditation evaluations shown in this Guide are performed by the National Committee for Quality Assurance (NCQA), the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), and URAC. Compare the accreditation status of different health plans with the following key (a lower number means a better accredited plan). Member Survey results, shown in the plan comparison sections, are collected, scored, and reported by an independent organization – not by the health plans. Here is a brief explanation of each survey category. Overall Plan Satisfaction Getting Needed Care Getting Care Quickly How Well Doctors Communicate Customer Service • How would you rate your overall experience with your health plan? • Were you satisfied with the choices your health plan gave you to select a personal doctor? • Were you satisfied with the time it takes to get a referral to a specialist? • Did you get the advice or help you needed when you called your doctor during regular office hours? • Could you get an appointment for regular or routine care when you wanted? • Did your doctor listen carefully to you and explain things in a way you could understand? • Did your doctor spend enough time with you? • Was your plan helpful when you called its customer service department? • Did you have paperwork problems? • Were the plan’s written materials understandable? • Did your plan pay your claims correctly and in a reasonable time? Claims Processing 11 Preventing Medical Mistakes An influential report from the Institute of Medicine estimates that up to 98,000 Americans die every year from medical mistakes in hospitals alone. That’s about 3,230 preventable deaths in the FEHB Program a year. While death is the most tragic outcome, medical mistakes cause other problems such as permanent disabilities, extended hospital stays, longer recoveries, and even additional treatments. By asking questions, learning more and understanding your risks, you can improve the safety of your own health care, and that of your family members. Take these simple steps: 1. Ask questions if you have doubts or concerns. • Ask questions and make sure you understand the answers. • Choose a doctor with whom you feel comfortable talking. • Take a relative or friend with you to help you ask questions and understand answers. 2. Keep and bring a list of all the medicines you take. • Give your doctor and pharmacist a list of all the medicines that you take, including non-prescription medicines. • Tell them about any drug allergies you have. • Ask about side effects and what to avoid while taking the medicine. • Read the label when you get your medicine, including all warnings. • Make sure your medicine is what the doctor ordered and know how to use it. • Ask the pharmacist about your medicine if it looks different than you expected. 3. Get the results of any test or procedure. • Ask when and how you will get the results of tests or procedures. • Don’t assume the results are fine if you do not get them when expected, be it in person, by phone, or by mail. • Call your doctor and ask for your results. • Ask what the results mean for your care. 4. Talk to your doctor about which hospital is best for your health needs. • Ask your doctor which hospital has the best care and results for your condition if you have more than one hospital to choose from to get the health care you need. • Be sure you understand the instructions you get about follow-up care when you leave the hospital. 5. Make sure you understand what will happen if you need surgery. • Make sure you, your doctor, and your surgeon all agree on exactly what will be done during the operation. • Ask your doctor, “Who will manage my care when I am in the hospital?” • Ask your surgeon: Exactly what will you be doing? About how long will it take? What will happen after surgery? How can I expect to feel during recovery? • Tell the surgeon, anesthesiologist, and nurses about any allergies, bad reaction to anesthesia, and any medications you are taking. Want more information on patient safety? ➥ www.ahrq.gov/consumer/pathqpack.htm. The Agency for Healthcare Research and Quality makes available a wide-ranging list of topics not only to inform consumers about patient safety but to help choose quality healthcare providers and improve the quality of care you receive. ➥ www.npsf.org. The National Patient Safety Foundation has information on how to ensure safer healthcare for you and your family. ➥ www.talkaboutrx.org/consumer.html. The National Council on Patient Information and Education is dedicated to improving communication about the safe, appropriate use of medicines. ➥ www.leapfroggroup.org. The Leapfrog Group is active in promoting safe practices in hospital care. ➥ www.ahqa.org. The American Health Quality Association represents organizations and healthcare professionals working to improve patient safety. 12 FEHB Web Resources Use the FEHB web site for additional help in choosing the health plan that is right for you. The FEHB web site at www.opm.gov/insure/health can help you to choose your health plan. In addition to the information found in this Guide you will find: • An interactive tool that will allow you to find the health plans that service your area and will allow you to make side-by-side comparisons of the costs, benefits, and quality indicators of the plans that interest you. • Electronic versions of all health plan brochures. • An evaluation of how your plan compares to other plans and the FEHB average in important medical areas under the Health Plan Employer Data and Information Set (HEDIS). HEDIS is a set of standardized performance measures that allows users to reliably compare managed care health plan performance across specific clinical areas. The performance measures are related to many significant public health issues such as cancer, heart disease, asthma, and diabetes. Compare plan results at www.opm.gov/insure/health/hedis2002. • Information on enrolling, with the ability to enroll online for annuitants and employees of selected agencies. • Information on how plans in the FEHB Program coordinate benefit payments with Medicare. • A comprehensive set of Frequently Asked Questions and answers on all aspects of the Program. • An online version of the FEHB Handbook for detailed guidance on FEHB policies and procedures. You can also look at and download: • All of the FEHB Guides including the guide for USPS Employees, the FEHB Guide for United States Postal Service Inspectors and Office of Inspector General Employees, the FEHB Guide for Certain Temporary (Non-career) USPS Empoyees, and the FEHB Guide for TCC and Former Spouse Enrollees. • Plan brochures that include benefits, cost, and other major features of each health plan. 13 Stop Health Care Fraud F raud increases the cost of health care for everyone and increases your Federal Employees Health Benefits Program (FEHBP) premium. OPM’s Office of the Inspector General investigates all allegations of fraud, waste, and abuse in the FEHBP regardless of the agency that employs you or from which you retired. Protect Yourself From Fraud - Here are some things you can do to prevent fraud: • Be wary of giving your health plan identification number over the telephone or to people you do not know, except to your doctor, other provider, or authorized plan or OPM representative. • Let only the appropriate medical professionals review your medical record or recommend services. • Avoid health care providers who say that an item or service is not usually covered, but they know how to bill your health plan to get it paid. • Carefully review explanations of benefits (EOBs) that you receive from your health plan. • Do not ask your doctor to make false entries on certificates, bills or records in order to get your health plan to pay for an item or service. • If you suspect that a provider has charged you for services you did not receive, billed you twice for the same service, or misrepresented any information, do the following: • Call the provider and ask for an explanation. There may be an error. • If the provider does not resolve the matter, call your health plan and explain the situation. • If they do not resolve the issue: CALL -- THE HEALTH CARE FRAUD HOTLINE 202-418-3300 OR WRITE TO: The United States Office of Personnel Management Office of the Inspector General Fraud Hotline 1900 E Street, NW, Room 6400 Washington, DC 20415 • Do not maintain as a family member under your FEHB coverage: • your former spouse after a divorce decree or annulment is final (even if a court orders it); or • your child over age 22 unless he/she is incapable of self support. • If you have any questions about the eligibility of a dependent, check with your local personnel office. • You can be prosecuted for fraud and your agency may take action against you if you falsify a claim to obtain FEHBP benefits or try to obtain services for someone who is not an eligible family member or who is no longer enrolled in the Plan. 14 USPS Employees: Table of Permissible Changes in FEHB Enrollment and Pre-Tax/After-Tax Premium Payment T he chart 1 below combines and replaces the OPM chart titled “Table of Permissible Changes in Enrollment for SF2809,” previously published in the SF2809 Health Benefits Election Form, and the list of qualified life status changes published in previous editions of RI 70-2, Guide to Federal Employees Health Benefits Plans For United States Postal Service Employees, and the FEHB guides for USPS law enforcement and noncareer employees. (Since USPS is using PostalEASE for Federal Employees Health Benefits (FEHB) elections, SF2809 is no longer used.) This chart uses the term “qualifying life event,” while in PostalEASE and other USPS information sources: 1. the term “permitting event” is used to describe events that allow an FEHB enrollment change—refer to the column in the Table labeled “FEHB Enrollment Change that May Be Permitted” and the headers “From Enrolled to Not Enrolled,” “From Self Only to Self and Family,” and “From One Plan or Option to Another;” 2. the term “qualified life status change” is used to describe events that allow employees who are paying premiums on a pre-tax basis to cancel coverage, or to reduce coverage from Self and Family to Self Only— refer to the column in the Table labeled “FEHB Enrollment Change that May Be Permitted” and the header “Cancel or Change to Self Only;” 3. the term “qualified life status change” is used to describe events that allow employees to waive (end) or participate (begin) pre-tax payment of health insurance premiums—refer to the column in the Table labeled “Premium Conversion Election Change that May Be Permitted.” All employees must meet the time limits stated in the far right column. Employees who are paying premiums on a pre-tax basis may only make changes that are in keeping with, or on account of, the change described in the table. For example, if you have a new baby, you would usually not cancel coverage. This restriction does not apply to open season changes, or to the initial opportunity to enroll. USPS career employees are automatically enrolled for pre-tax payment of health insurance premiums; noncareer employees must elect it. Employees who are paying premiums on an after-tax basis may cancel coverage or reduce coverage from Self and Family to Self Only at any time—they do not need to have an event. 1 This chart does not apply to Federal employees, only USPS employees. 15 USPS Employees: Table of Permissible Changes in FEHB Enrollment and Pre-Tax/After-Tax Premium Payment See explanatory note on first page of this chart. QUALIFYING LIFE EVENTS (QLES) THAT MAY PERMIT CHANGE IN FEHB ENROLLMENT OR FEHB ENROLLMENT CHANGE THAT MAY BE PERMITTED PREMIUM CONVERSION ELECTION Code Event From Not From Self From One Enrolled to Only to Self Plan or Enrolled and Family Option to Another Yes N/A N/A Cancel or Change to Self Only N/A PREMIUM CONVERSION ELECTION CHANGE THAT MAY BE PERMITTED Participate Waive TIME LIMITS IN WHICH CHANGE MAY BE PERMITTED When You Must File Health Benefits Election with Your Employing Office 1A Initial Opportunity to Enroll, for example: • New employee • Change from excluded position • Temporary (Non-career) employee who completes 1 year of service and is eligible to enroll under 5 USC 8906a Open Season Change in family status that results in increase or decrease in number of eligible family members, for example: • Marriage, divorce, annulment, legal separation • Birth, adoption, acquiring foster child or stepchild, issuance of court order requiring employee to provide coverage for child • Last dependent child loses coverage, for example child reaches age 22 or marries, stepchild moves out of employee’s home, disabled child becomes capable of self-support, child acquires other coverage by court order • Death of spouse or dependent Any change in employee’s employment status that could result to entitlement to coverage, for example: • Reemployment after a break in service of more than 3 days • Return to pay status from nonpay status, or return to receiving pay sufficient to cover premium withholdings, if coverage terminated (If coverage did not terminate, see 1G) Any change in employee’s employment status that could affect the cost of insurance, including: • Change from temporary appointment with eligibility for coverage under 5 USC 8906a to appointment that permits receipt of government contribution • Change from full time to part time career or the reverse Within 60 days after Yes Automatic unless waived (Automatic becoming eligible for (except for temporary temporary employees) employees) 1B 1C Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes As announced by OPM Within 60 days after change in family status Employees may enroll or change beginning 31 days before the event 1D Yes N/A N/A N/A Automatic unless waived Yes Within 60 days after employment status change 1E Yes Yes Yes Yes Yes Yes Within 60 days after employment status change 16 USPS Employees: Table of Permissible Changes in FEHB Enrollment and Pre-Tax/After-Tax Premium Payment See explanatory note on first page of this chart. QUALIFYING LIFE EVENTS (QLES) THAT MAY PERMIT CHANGE IN FEHB ENROLLMENT OR FEHB ENROLLMENT CHANGE THAT MAY BE PERMITTED PREMIUM CONVERSION ELECTION Code Event From Not From Self From One Enrolled to Only to Self Plan or Enrolled and Family Option to Another Yes Yes Yes Cancel or Change to Self Only 2 Yes PREMIUM CONVERSION ELECTION CHANGE THAT MAY BE PERMITTED Participate Waive TIME LIMITS IN WHICH CHANGE MAY BE PERMITTED When You Must File Health Benefits Election with Your Employing Office Within 60 days after return to civilian position Within 60 days after employment status change 1F Employee restored to civilian position after serving in uniformed service 3 Yes Yes 1G Employee, spouse or dependent: • begins nonpay status or insufficient pay 4 or • ends nonpay status or insufficient pay if coverage continued • (If employee’s coverage terminated, see 1D) • (If spouse’s or dependent’s coverage terminated, see 1M) Salary of temporary employee insufficient to make withholdings for plan in which enrolled Employee (or covered family member) enrolled in FEHB health maintenance organization (HMO) moves or becomes employed outside the geographic area from which the FEHB carrier accepts enrollments or, if already outside the area, moves further from this area. 5 Transfer from post of duty within a state of the United States or the District of Columbia to post of duty outside a State of the United States or District of Columbia, or reverse Separation from Federal Employment when the employee or employee’s spouse is pregnant Employee becomes entitled to Medicare and wants to change to another plan or option. 6 No No No Yes Yes Yes 1H N/A No Yes Yes Yes Yes Within 60 days after receiving notice from employing office Upon notifying employing office of move 1I N/A Yes Yes N/A (see M1) No (see M1) No (see M1) 1J Yes Yes Yes Yes Yes Yes Employees may enroll or change beginning 31 days before leaving the old post of duty Yes Yes Yes N/A N/A N/A Within 60 days after arriving at new post 1K During empoyee’s final pay period 1L No No Yes (Change may be made only once) N/A (see M1) No (see M1) No (see M1) Any time beginning on the 30th day before becoming eligible for Medicare 2 Employees may change to Self Only outside of Open Season only if the QLE caused the enrollee to be the last eligible family member under the FEHB enrollment. Employees may cancel enrollment outside if Open Season only if the QLE caused the enrollee and all the eligible family members to acquire other health insurance coverage. 3 Employees who enter active military service are given the opportunity to terminate coverage. Termination for this reason does not count against the employee for purposes of meeting the requirements for continuing coverage after retirement. Additional information on the FEHB coverage of employees who return from active military service will be forthcoming. 4 Employees who begin nonpay status or insufficient pay must be given an opportunity to elect to continue or terminate coverage. A termination differs from a cancellation as it allows conversion to nongroup cov- erage and does not count against the employee for purposes of meeting the requirements for continuing coverage after retirement. 17 USPS Employees: Table of Permissible Changes in FEHB Enrollment and Pre-Tax/After-Tax Premium Payment See explanatory note on first page of this chart. QUALIFYING LIFE EVENTS (QLES) THAT MAY PERMIT CHANGE IN FEHB ENROLLMENT OR FEHB ENROLLMENT CHANGE THAT MAY BE PERMITTED PREMIUM CONVERSION ELECTION Code Event From Not From Self From One Enrolled to Only to Self Plan or Enrolled and Family Option to Another Yes Yes Yes Cancel or Change to Self Only Yes PREMIUM CONVERSION ELECTION CHANGE THAT MAY BE PERMITTED Participate Waive TIME LIMITS IN WHICH CHANGE MAY BE PERMITTED When You Must File Health Benefits Election with Your Employing Office Within 60 days after loss of coverage 1M Employees or eligible family member loses coverage under FEHB or another group insurance plan including the following: • Loss of coverage under another FEHB enrollment due to termination, cancellation, or change to self-only of the covering enrollment • Loss of coverage due to termination of membership in employee organization sponsoring the FEHB plan 7 • Loss of coverage under another federally-sponsored health benefits program, including: TRICARE, Medicare, Indian Health Service • Loss of coverage under Medicaid or similar State-sponsored program of medical assistance for the needy • Loss of coverage under a non-Federal health plan, including foreign, state or local government, private sector • Loss of coverage due to change in worksite or residence (Employees in an FEHB HMO, also see 1I) Loss of coverage under a non-Federal group health plan because an employee moves out of the commuting area to accept another position and the employee’s non-Federally employed spouse terminates employment to accompany the employee Yes Yes Employees may enroll or change beginning 31 days before the event 1N Yes Yes Yes Yes Yes Yes From 31 days before the employee leaves the commuting area to 180 days after arriving in the new commuting area 5 This code reflects the FEHB regulation that gives employees enrolled in an FEHB HMO who change from Self Only to Self and Family or from one plan or option to another a different timeframe than that allowed under 1M. For change to Self Only, cancellation, or change in premium conversion status see 1M. 6 This code reflects the FEHB regulation that gives employees enrolled in FEHB a one-time opportunity to change plans or options under a different timeframe than that allowed by 1P. For change to Self Only, cancella- tion, or change in premium conversion status, see 1P. 7 If employees membership terminates, (e.g., for failure to pay membership dues), the employee organization will notify the agency to terminate the enrollment. 18 USPS Employees: Table of Permissible Changes in FEHB Enrollment and Pre-Tax/After-Tax Premium Payment See explanatory note on first page of this chart. QUALIFYING LIFE EVENTS (QLES) THAT MAY PERMIT CHANGE IN FEHB ENROLLMENT OR FEHB ENROLLMENT CHANGE THAT MAY BE PERMITTED PREMIUM CONVERSION ELECTION Code Event From Not From Self From One Enrolled to Only to Self Plan or Enrolled and Family Option to Another Yes Yes Yes Cancel or Change to Self Only Yes PREMIUM CONVERSION ELECTION CHANGE THAT MAY BE PERMITTED Participate Waive TIME LIMITS IN WHICH CHANGE MAY BE PERMITTED When You Must File Health Benefits Election with Your Employing Office During open season, unless OPM sets a different time Within 60 days after QLE 1O Employee or eligible family member loses coverage due to discontinuation in whole or part of FEHB plan 8 Employee or eligible family member gains coverage under FEHB or another group insurance plan, including the following: • Medicare (Employees who become eligible for Medicare and want to change plans or options, see 1I) • TRICARE for Life, due to enrollment in Medicare • TRICARE due to change in employment status, including: (1) entry into active military service, (2) retirement from reserve military service under chapter 67, title 10 • Medicaid or similar state sponsored program of medical assistance for the needy • Health insurance acquired due to change of worksite or residence that affects eligibility for coverage • Health insurance acquired due to spouse’s or dependent’s change in employment status (including state, local or foreign government or private sector employment) 9 Change in spouse’s or dependent’s coverage options under a non-Federal health plan, for example: • Employer starts or stops offering a different type of coverage (If no other coverage is available, also see 1M) • Change in cost of coverage • HMO adds a geographic service area that now makes spouse eligible to enroll in that HMO • HMO removes a geographic area that makes spouse ineligible for coverage under that HMO, but other plans or options are available (If no other coverage is available, see 1M) Yes Yes 1P No No No Yes Yes Yes 1Q No No No Yes Yes Yes Within 60 days after QLE 8 Employee’s failure to select another FEHB plan is deemed a cancellation for purposes of meeting the requirements for continuing coverage after retirement. 9 Under IRS rules, this includes start/stop of employment or nonpay status, strike or lockout, and change in worksite. 19 How to Use PostalEASE Manage Your Federal Employees Health Benefits (FEHB) Enrollment The PostalEASE telephone system and web site provide a convenient, confidential, and secure way for you to newly enroll, change your current enrollment, or cancel your enrollment in the Federal Employees Health Benefits (FEHB) Program. If you have access to PostalEASE on the Intranet (from the blue page) or at an Employee Self-Service Kiosk (available in some facilities), using either of these may be easier than using the telephone. Through PostalEASE you may: • Make a change to your current enrollment during FEHB Open Season (November 10, 2003 – December 9, 2003, 5 PM Central Time). • Make an election as a new employee within 60 days of your date of hire. • Enter your dependents’ information, confirming any names already listed and adding any new names. Note that as some insurance carriers have provided dependent names on a one-time basis, the names may appear in PostalEASE, but they may not be up to date. Be sure to confirm your dependent list. Note also that PostalEASE will not transmit dependent change information to the insurance carrier if an enrollment transaction has not occurred. If you are not making a change in your enrollment at the same time, contact your health plan carrier directly with information on dependents. You cannot use PostalEASE to newly enroll or change your enrollment due to the occurrence of a permitting event, nor to cancel or reduce your coverage due to a qualified life status change. You must contact your local personnel office to assist you with these actions. If you are not making any changes to your current FEHB enrollment, then you do not need to do anything. Preparing for PostalEASE FEHB Enrollment 1. Read the Privacy Act Statement on the other side of this page. 2. Read and understand the RI 70-2, Guide to the FEHB Plans, which is mailed to you each FEHB Open Season. 3. Make sure you have the following information ready before using PostalEASE. a. Your USPS personal identification number (PIN) If you don’t know your PIN, just call PostalEASE. When prompted to enter your PIN, pause and you will be given the option of having it mailed to your address of record. Usually it will be mailed by the next business day. Or, request your USPS PIN from PostalEASE on the Intranet (from the blue page) or at an employee Self-Service Kiosk (available in some facilities). b. Your Social Security Number (SSN). c. Your daytime phone number. d. The name of the health benefits plan in which you are enrolling. e. The code of the health benefits plan in which you are enrolling. For the name and code, refer to the list of codes in RI 70-2, Guide to FEHB Plans, or to the health plan brochure. f. The names, SSNs (optional), addresses, and dates of birth for all eligible family members that will be covered under your health benefits enrollment. For more information on family member eligibility, see RI 70-2, Guide to FEHB Plans. g. The insurance company name and policy number of any other group insurance you or any of your eligible family members may have (including Tricare, Medicare, etc.). h. If you are changing plans or cancelling coverage, the code of the health benefits plan in which you are currently enrolled – that is, the plan that you will not have after your choice takes effect. The code for your current plan is found on your biweekly earnings statement. It is the three-character code that follows the letters “HP or “HB.” For example, the Blue Cross Self and Family Standard plan will be shown as HP105 or HB105, and you will enter the code 105 in PostalEASE. You may also refer to the list of codes in RI 70-2, Guide to FEHB Plans. 4. Complete the worksheet that follows, using the information you prepared above. 20 PostalEASE FEHB Worksheet This worksheet will help you prepare to call PostalEASE, or use PostalEASE on the Intranet (from the blue page), or on an Employee Self-Service Kiosk (now available in some facilities). You may also prepare this worksheet and contact your local personnel office if you cannot enroll or make a change because PostalEASE does not accept the required documentation. Note: If you have any trouble using PostalEASE, or if you are unable to use the telephone because you are deaf or hard of hearing, or you cannot use the telephone, Intranet, or Employee Self-Service Kiosk for medical reasons, you may contact your local personnel office for assistance. If you contact your local personnel office, be sure to complete this worksheet first. Part 1 – Employee Information Your Name (Last, First, Middle Initial) Social Security Number Type Of Action You Are Requesting Open Season: New Hire: ❑ New Enrollment ❑ New Enrollment ❑ Change Current Enrollment ❑ Waive Enrollment ❑ Cancel Enrollment ❑ Cancel Enrollment Special Enrollment (if you are notified that your current plan is being discontinued or your service are is reduced): ❑ Change Current Enrollment New Plan Enrollment Code _____________ New Plan Name ________________________________________________ Old Plan Enrollment Code (if you are changing plans or cancelling your current plan) __________________________________ Please note: Changes due to a permitting event or a qualified life status change (QLSC) cannot be made via PostalEASE. If you wish to make any change that is not listed under “Type of Action You Are Requesting” above, you must contact your local personnel office. You will need to present documentation showing that your election is due to a permitting event or QLSC and that you are contacting personnel within the required timeframe. For more information on permitting events and QLSCs, please refer to the RI 70-2, Guide to FEHB Plans, which is mailed to you each FEHB Open Season. Your Other Group Insurance (Not used for cancelling enrollment or waiving enrollment as a new employee) Do you have any group health insurance coverage other than under the FEHB plan in which you are now enrolling or already enrolled? ❑ Yes ❑ No ❑ Medicare Part A ❑ Medicare Part B ❑ Tricare or Champus Policy No. (if known) _____________________ Other Group Insurance Co. Name _______________________________________________________________ Policy No. (if known) ___________________________________________ Identify Type of Other Insurance Coverage Your Gender: ❑ Male ❑ Female Married: ❑ Yes ❑ No 21 Daytime Telephone Number (with area code) PostalEASE FEHB Worksheet Part 2 – Dependent Information (for Self and Family coverage only) A complete mailing address (if different from yours) and other insurance information (if any) must be provided for each covered dependent. If you are adding or updating information for a dependent who does not reside with you, you will need to use the PostalEASE Employee Web on the Intranet (blue page) or at an Employee Self-Service Kiosk (available in some facilities) or visit your local personnel office to make or change your FEHB enrollment. ❑ Please check here if all dependents reside with you. Family Members Names (Last, First, Middle Initial) Address (Street, City, State, Zip) (If different from yours) Gender Date of Relationship Birth Code* SSN (Optional) Other Group Insurance Co. Name & Policy No. * Relationship Codes: 01 = Spouse 02 = Spouse from a common law marriage (requires certification to be filed with local personnel office) 19 = Child 09 = Adopted child 10 = Foster child (requires certification to be filed with local personnel office) 17 = Stepson or stepdaughter (if living with you in a parent-child relationship) 99 = Unmarried child over age 22 incapable of self-support (requires certification to be filed with local personnel office) _________________________________________________________________ Employee Signature _________________________________________________ Confirmation Number You Receive From PostalEASE For Personnel Office Use Only Remarks: Specific information on type pf permitting event or QLSC, reason for correction, type of certification, supporting documentation, reason for verification, etc., should be provided here. Personnel Office _____________________________________________ Date Received in Personnel Office (employee election date) _________ Address ______________________________________________________________________________________________________ Contact Name __________________________________________________________________________________________________ Telephone Number ___________________________________________________ Date of Event/QLSC/Birth _________________________ File copy in OPF for any FEHB transaction processed by HR and ASC 22 How to Use PostalEASE Now that you have completed the worksheet, you are ready to call PostalEASE. • If you have access to the PostalEASE Employee Web on the Intranet (from the blue page) or to an employee SelfService Kiosk (available in some facilities), using either may be simpler than using the telephone. Just follow the instructions. • Otherwise, call PostalEASE toll-free at 1-800-4PS-EASE • When prompted, select Federal Employees Health Benefits. • Follow the script and prompts to enter your SSN, your USPS PIN, and other required information. (Having your completed PostalEASE FEHB Worksheet on hand will help you complete your transaction. • If you currently have an FEHB enrollment and you do not want to make any changes… do nothing. (1-877-477-3273) WARNING: Any intentionally false statement in this application or willful misrepresentation relative thereto is a violation of the law punishable by a fine of not more than $10,000 or imprisonment of not more than 5 years, or both. (18 U.S.C. 1001) PRIVACY ACT STATEMENT: The collection of this information is authorized by 39 USC 401, 1001,1003,1005; 5 usc 8339; 42 USC 2000e-1 6, and Executive Orders 11478 arid 11590. This information will be used to process your enrollment in the Federal Employees Health Benefit system and to manage your claim under that plan. As a routine use, the information may be disclosed to an appropriate government agency, domestic or foreign, for law enforcement purposes; where pertinent, in a legal proceeding to which the USPS is a party or has an interest; to a government agency in order to obtain information relevant to a USPS decision concerning employment, security clearances, contracts, licenses, grants, permits or other benefits; to a government agency upon its request when relevant to its decision concerning employment, security clearances, security or suitability investigations, contracts, licenses, grants or other benefits; to a congressional office at your request; to an expert, consultant, or other person under contract with the USPS to fulfill an agency function; to the Federal Records Center for storage; to the Office of Management and Budget for review of private relief legislation; to an independent certified public accountant during an official audit of USPS finances; to an investigator, administrative judge or complaints examiner appointed by the Equal Employment Opportunity Commission for investigation of a formal EEO complaint under 29 CFR 1614; to the Merit Systems Protection Board or Office of Special Counsel for proceedings or investigations involving personnel practices and other matters within their jurisdiction; to a labor organization as required by the National Labor Relations Act; to agencies having taxing authority for taxing purposes; to financial organizations receiving allotments; to State Employment Security Agencies to process unemployment compensation claims; to a Federal or state agency providing parent locator service or to other authorized persons as defined by Pub. L. 93-647; to the National Association of Postal Supervisors that relates to postal supervisors; to a prospective employer for consideration of employment; to management for compilation of a local seniority list for posting; to the EEOC for enforcement of Federal EEO regulations; to the appropriate finance center as required under the provisions of the Dual Compensation Act; to the Office of Personnel Management, Social Security Administration, Veterans Administration, Office of Workers’ Compensation Programs; health insurance carriers, or plans, or other program management agencies or retirement systems for use in determining a claim for benefits; and to OPM for its active employee/annuitant data systems used to analyze Federal retirement and insurance costs. Providing the information is voluntary; however, if this information is not provided, we may not be able to process your enrollment. We also request that you provide your social security number so that it may be used as your individual identifier in the Federal Employee Health Benefits system. Executive order 9397 dated November 22, 1943, allows Federal Agencies to use the social security number as an individual identifier to distinguish between people with the same or similar names. Computer Matching: Limited information may be disclosed to a Federal, state, or local government administering benefits or other programs pursuant to statute for purpose of conducting computer matching programs under the Act. These programs include, but are not limited to, matches performed to verify an individual’s initial or continuing eligibility for, indebtedness to, or compliance with requirements of a benefit program. 23 This page intentionally left blank 24 Plan Comparisons Nationwide Fee-For-Service Plans Open to All (Pages 26 through 29) Fee-For-Service (FFS) Plans with a Preferred Provider Organization (PPO) — An FFS plan that allows you to see medical providers who reduce their charges to the plan; you pay less money out-of-pocket when you use a PPO provider. When you visit a PPO you usually won’t have to file claims or paperwork. However, going to a PPO hospital does not guarantee PPO benefits for all services received within that hospital. For instance, lab work and radiology services from independent practitioners within the hospital are frequently not covered by the PPO agreement. Fee-For-Service (FFS) Plans (non-PPO) — An FFS plan that either pays the medical provider directly or reimburses you for covered medical expenses. When you need medical attention, you visit the doctor or hospital of your choice. In PPO-only options, you must use PPO providers to receive benefits. Consumer-Driven Plans — Describes a wide range of approaches to give you more incentive to control the cost of either your health benefits or health care. You have greater freedom in spending health care dollars up to a designated amount, and you receive full coverage for in-network preventive care. In return, you assume significantly higher cost sharing expenses after you have used up the designated amount. The catastrophic limit is usually higher than those common in other plans. 25 Nationwide Fee-for-Service Plans Open to All How to read this chart: The table below highlights selected features that may help you narrow your choice of health plans. Always consult plan brochures before making your final decision. The chart does not show all of your possible out-of-pocket costs. The Deductibles shown are the amount of covered expenses that you pay before your health plan begins to pay. Calendar Year deductibles for families are two or more times the per person amount shown. In some plans your combined Prescription Drug purchases from Mail Order and local pharmacies count toward the deductible. In other plans, only purchases from local pharmacies count. Some plans require each family member to meet a per person deductible. The Hospital Inpatient deductible is what you pay each time you are admitted to a hospital. Doctors shows what you pay for inpatient surgical services and for office visits. Your share of Hospital Inpatient Room and Board covered charges is shown. The Generic drug figure is the copayment or coinsurance most commonly paid by members of this health plan for a Generic formulary drug. Enrollment Code Biweekly Premium Your Share Plan Name APWU Health Plan-High (APWU) APWU Health Plan-Consumer driven (APWU) Blue Cross and Blue Shield Service Benefit Plan-Std (BCBS) Blue Cross and Blue Shield Service Benefit Plan-Basic (BCBS) GEHA Benefit Plan-High (GEHA) GEHA Benefit Plan-Std (GEHA) Mail Handlers-High (MH) Mail Handlers-Std (MH) NALC PBP Health Plan-High (PBP) PBP Health Plan-Std (PBP) Telephone Number 800/222-2798 800/222-2798 Local phone # Local phone # 800/821-6136 800/821-6136 800/410-7778 800/410-7778 888/636-6252 800-544-7111 800-544-7111 Self only 471 474 104 111 311 314 451 454 321 361 364 Self & family 472 475 105 112 312 315 452 455 322 362 365 Self only $35 $17.53 $26.98 $17.10 $54.32 $13.61 $73.67 $14.47 $29.76 $161.14 $45.98 Self & family $64 $40.81 $62.85 $40.05 $103.02 $30.94 $130.58 $31.42 $42.75 $329.75 $101.67 26 Brand Name/Non-formulary is what you pay for a manufacturer’s Brand name drug on this health plan’s formulary. You pay the Brand name amount if you or your doctor request the Brand name or if a Generic is not available. The figure in this column is the copayment or coinsurance most commonly paid by members of this health plan for a Brand name formulary drug. If a Non-formulary drug is prescribed and the cost to you is different than the Brand name, you pay the second amount if listed. Mail Order Discounts. If your plan has a Mail Order program and that program is superior to the purchase of medications at the pharmacy (e.g., you get a greater quantity or pay less through Mail Order), your plan’s response is "yes." If the plan does not have a Mail Order program or it is not superior to its pharmacy benefit, the plan’s response is "no." The prescription drug copayments or coinsurances described in this chart do not represent the complete range of cost-sharing under these plans. Many plans have variations in their prescription drug benefits (e.g., you pay the greater of a dollar amount or a percentage, or you pay one amount for your first prescription and then a different amount for refills). The prescription drug figures in this chart show what most plan members pay for their medications under each plan. You must read the plan brochure for a complete description of prescription drug and all other benefits. Medical-Surgical – You Pay Deductible Per Person Calendar Prescription Year Drug $275 $500 $600 * $600 * $250 $250 None $350 $350 $450 $450 $250 $300 $300 $350 $250 $300 $200 $500 $250 $600 None None None None None None None None None None None $200 $200 $400 $400 None $25 $90 $90 $90 $90 Copay ($)/Coinsurance (%) Doctors Hospital Inpatient Office Visits $18 30% 15% 40% $15 25% $20/$30 $20 25% $10 35% $20/$10 30% $20/$10 30% $20 30% 10% 20% $8 30% Benefit Type Plan APWU-High APWU BCBS -Std BCBS -Basic PPO Non-PPO PPO Non-PPO PPO Non-PPO PPO PPO Non-PPO PPO Non-PPO PPO Non-PPO PPO Non-PPO PPO Non-PPO PPO Non-PPO PPO Non-PPO Inpatient Surgical Services 10% 30% 15% 40% 10% 25% $100 10% 25% 15% 35% 10% 30% 10% 30% 10% 30% 10% 25% 9% 30% Hospital Inpatient R&B 10% 30% 15% 40% Nothing 30% Nothing Nothing Nothing 15% 35% Nothing 30% Nothing 30% 10% 30% 10% 25% 9% 30% Prescription Drugs Generic $8 50% 25% N/A 25% 45%+ $10 $5 $5 $5 $5 $10 50% $10 50% 25% 50% $3 20%+ $4 30%+ Brand Name / 25% 50% Nonformulary Mail Order Discounts Yes No No No Yes No No Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes None $300 None None $100 $300 $100/day x 5 $100 $300 None None $100 $300 $200 $400 None $100 None $150 None $250 25%/25% N/A 25% 45%+ $25/$35 or 50% $25 $25 50% 50% $25/$40 50% $30/$45 50% 25% 50%+ $25 or 20%/$40 or 20% 20%+ $30 or 20%/$40 or 20% 30%+ GEHA -High GEHA -Std MH -High MH -Std NALC PBP -High PBP -Std *Rollover from previous year may reduce your deductible. 27 Nationwide Fee-for-Service Plans Open to All Member Survey results are collected, scored, and reported by an independent organization – not by the health plans. Here is a brief explanation of each survey category. Overall Plan Satisfaction Getting Needed Care Getting Care Quickly How Well Doctors Communicate Customer Service • How would you rate your overall experience with your health plan? • Were you satisfied with the choices your health plan gave you to select a personal doctor? • Were you satisfied with the time it takes to get a referral to a specialist? • Did you get the advice or help you needed when you called your doctor during regular office hours? • Could you get an appointment for regular or routine care when you wanted? • Did your doctor listen carefully to you and explain things in a way you could understand? • Did your doctor spend enough time with you? • Was your plan helpful when you called its customer service department? • Did you have paperwork problems? • Were the plan’s written materials understandable? • Did your plan pay your claims correctly and in a reasonable time? Claims Processing Member Survey Results h above average, * average, f below average Overall plan satisfaction Getting needed care Getting care quickly How well doctors communicate h h * f * * * * h h h Customer service Claims processing Plan Name APWU Health Plan-High APWU Health Plan-Consumer driven Blue Cross and Blue Shield Service Benefit Plan-Std Blue Cross and Blue Shield Service Benefit Plan-Basic GEHA Benefit Plan-High GEHA Benefit Plan-Std Mail Handlers-High Mail Handlers-Std NALC PBP Health Plan-High PBP Health Plan-Std Plan Code 47 47 10 11 31 31 45 45 32 36 36 h h * f h h f f h * * * * * f * * * * h * * h h * f * * f f h h h h h f f h h * * h f f h h * f h h * * h f f 28 Fee-For-Service Plans – Blue Cross and Blue Shield Service Benefit Plan – Member Survey Results for Select States This year we are providing more detailed information regarding the quality of services provided by our health plans. We are including the results of the Member Satisfaction survey at the state level for eight local Blue Cross Blue Shield (BCBS) Plans. In the past, BCBS has conducted a single survey representing all of its members nation-wide. This year, however, we are able to provide local member satisfaction results for both the Standard Option plan and the Basic Option plan. In the future, we expect to increase the number of plans conducting local or regional Member Satisfaction surveys. We look forward to making those results available to help you select quality health plans. Below are Member Survey ratings for local BCBS plans by location: Member Survey Results h above average, * average, f below average Overall plan Getting Getting satisfaction needed care care quickly How well doctors communicate f f * f * f f f * f * f * f * f Plan Name Blue Cross and Blue Shield Service Benefit Plan Blue Cross and Blue Shield Service Benefit Plan Blue Cross and Blue Shield Service Benefit Plan Blue Cross and Blue Shield Service Benefit Plan Blue Cross and Blue Shield Service Benefit Plan Blue Cross and Blue Shield Service Benefit Plan Blue Cross and Blue Shield Service Benefit Plan Blue Cross and Blue Shield Service Benefit Plan - Standard - Basic - Standard - Basic Location Arizona California Plan Code 10 11 10 11 10 11 10 11 10 11 10 11 10 11 10 11 Customer service Claims processing h f h f * f h f * f * f h f h f f f f f * f * f h f * f * f * f f f * f f f f f * f * f * f * f * f * f * f * f * f f f * f h * h f h f * * h * * f * f * f h h - Standard - Basic District of Columbia - Standard - Basic - Standard - Basic - Standard - Basic - Standard - Basic - Standard - Basic Florida Illinois Maryland Texas Virginia 29 This page intentionally left blank Plan Comparisons Nationwide Fee-For-Service Plans Open Only to Specific Groups (Pages 32 through 34) Fee-For-Service (FFS) Plans with a Preferred Provider Organization (PPO) — An FFS plan that allows you to see medical providers who reduce their charges to the plan; you pay less money out-of-pocket when you use a PPO provider. When you visit a PPO you usually won’t have to file claims or paperwork. However, going to a PPO hospital does not guarantee PPO benefits for all services received within that hospital. For instance, lab work and radiology services from independent practitioners within the hospital are frequently not covered by the PPO agreement. Fee-For-Service (FFS) Plans (non-PPO) — An FFS plan that either pays the medical provider directly or reimburses you for covered medical expenses. When you need medical attention, you visit the doctor or hospital of your choice. 31 Nationwide Fee-for-Service Plans Open Only to Specific Groups How to read this chart: The table below highlights selected features that may help you narrow your choice of health plans. Always consult plan brochures before making your final decision. The chart does not show all of your possible out-of-pocket costs. The Deductibles shown are the amount of covered expenses that you pay before your health plan begins to pay. Calendar Year deductibles for families are two or more times the per person amount shown. In some plans your combined Prescription Drug purchases from Mail Order and local pharmacies count toward the deductible. In other plans, only purchases from local pharmacies count. Some plans require each family member to meet a per person deductible. The Hospital Inpatient deductible is what you pay each time you are admitted to a hospital. Doctors shows what you pay for inpatient surgical services and for office visits. Your share of Hospital Inpatient Room and Board covered charges is shown. The Generic drug figure is the copayment or coinsurance most commonly paid by members of this health plan for a Generic formulary drug. Enrollment Code Biweekly Premium Your Share Plan Name Association Benefit Plan (ABP) Foreign Service Benefit Plan (FS) Panama Canal Area Benefit Plan (PCA) Rural Carrier Benefit Plan (Rural) SAMBA Secret Service Employees Health Association (SSEHA) Telephone Number 800/634-0069 202/833-4910 800/548-8969 800/638-8432 800/638-6589 800/296-0724 Self only 421 401 431 381 441 Y71 Self & family 422 402 432 382 442 Y72 Self only $36.84 $19.36 $17.12 $56.62 $48.79 $32.42 Self & family $87.89 $66.88 $35.74 $79.70 $125.30 $89.38 32 Brand Name/Non-formulary is what you pay for a manufacturer’s Brand name drug on this health plan’s formulary. You pay the Brand name amount if you or your doctor request the Brand name or if a Generic is not available. The figure in this column is the copayment or coinsurance most commonly paid by members of this health plan for a Brand name formulary drug. If a Non-formulary drug is prescribed and the cost to you is different than the Brand name, you pay the second amount if listed. Mail Order Discounts. If your plan has a Mail Order program and that program is superior to the purchase of medications at the pharmacy (e.g., you get a greater quantity or pay less through Mail Order), your plan’s response is "yes." If the plan does not have a Mail Order program or it is not superior to its pharmacy benefit, the plan’s response is "no." The prescription drug copayments or coinsurances described in this chart do not represent the complete range of cost-sharing under these plans. Many plans have variations in their prescription drug benefits (e.g., you pay the greater of a dollar amount or a percentage, or you pay one amount for your first prescription and then a different amount for refills). The prescription drug figures in this chart show what most plan members pay for their medications under each plan. You must read the plan brochure for a complete description of prescription drug and all other benefits. Medical-Surgical – You Pay Deductible Per Person Calendar Prescription Year Drug $300 $300 $300 $300 None None $350 $400 $350 $350 $200 $200 None None None None $400 $400 $200 $200 None None None None Copay ($)/Coinsurance (%) Doctors Hospital Inpatient Office Visits $10 30% 10% 30% $10 50% $20 25% $20 30% Benefit Type Plan ABP FS PCA Rural SAMBA SSEHA PPO Non-PPO PPO Non-PPO POS FFS PPO Non-PPO PPO Non-PPO Par Non-Par Inpatient Surgical Services 10% 30% 10% 30% Nothing 50% 10% 20% 10% 30% 20% 20%+diff. Hospital Inpatient R&B Nothing 30% Nothing 20% Nothing 50% Nothing 20% Nothing 30% Nothing 20%+diff. Prescription Drugs Generic $5 $5 $10/25% $10/25% 50% 50% 30% 30% $10 $10 $10 All chgs. Brand Name / 50% 50% 30% 30% Mail Order Nonformulary Discounts Yes Yes Yes Yes No Yes Yes Yes Yes Yes No $100 $300 Nothing $200 $50 $125 $100 $300 $200 $300 $25/$40 $25/$40 $20/25%/N/A $20/25%/N/A $25/$40 $25/$40 $20 All chgs $100 20% $100+any diff. 20%+diff. 33 Nationwide Fee-for-Service Plans Open Only to Specific Groups Member Survey results are collected, scored, and reported by an independent organization – not by the health plans. Here is a brief explanation of each survey category. Overall Plan Satisfaction Getting Needed Care Getting Care Quickly How Well Doctors Communicate Customer Service • How would you rate your overall experience with your health plan? • Were you satisfied with the choices your health plan gave you to select a personal doctor? • Were you satisfied with the time it takes to get a referral to a specialist? • Did you get the advice or help you needed when you called your doctor during regular office hours? • Could you get an appointment for regular or routine care when you wanted? • Did your doctor listen carefully to you and explain things in a way you could understand? • Did your doctor spend enough time with you? • Was your plan helpful when you called its customer service department? • Did you have paperwork problems? • Were the plan’s written materials understandable? • Did your plan pay your claims correctly and in a reasonable time? Claims Processing h Member Survey Results above average, * average, f below average Getting needed care Getting care quickly How well doctors communicate Customer service Claims processing Overall plan satisfaction Plan Name Association Benefit Plan Foreign Service Benefit Plan Panama Canal Area Benefit Plan Rural Carrier Benefit Plan SAMBA Secret Service Employees Health Association Plan Code 42 40 43 38 44 Y7 h * f h h f * f h h f * h f * h * f * f h * * f h f h h * f h f f h h f 34 Plan Comparisons Health Maintenance Organization Plans, Plans Offering a Point of Service Product, and Local Consumer-Driven Plans (Pages 36 through 65) Health Maintenance Organization (HMO) — A health plan that provides care through a network of physicians and hospitals in particular geographic or service areas. HMOs coordinate the health care service you receive and free you from completing paperwork or being billed for covered services. Your eligibility to enroll in an HMO is determined by where you live or, for some plans, where you work. Some HMOs are affiliated with or have arrangements with HMOs in other service areas for non-emergency care if you travel or are away from home for extended periods ( reciprocity). Plans that offer reciprocity discuss it in their brochure. ● The HMO provides a comprehensive set of services — as long as you use the doctors and hospitals affiliated with the HMO. HMOs charge a copayment for primary physician and specialist visits and generally no coinsurance for inhospital care. ● Most HMOs ask you to choose a doctor or medical group to be your primary care physician (PCP). Your PCP provides your general medical care. In many HMOs, you must get authorization or a “referral” from your PCP to see other providers. The referral is a recommendation by your physician for you to be evaluated and/or treated by a different physician or medical professional. The referral ensures that you see the right provider for the care most appropriate to your condition. ● Care is not covered from a provider not in the plan’s network unless it’s emergency care or your plan has an arrangement with another plan. Plans Offering a Point of Service (POS) Product — A product similar to an HMO and FFS plan. The POS product lets you use providers who are not part of the HMO network for some services. However, you pay more for using these non-network providers. You usually pay higher deductibles and coinsurances than you pay with a plan provider. You will also need to file a claim for reimbursement, like in an FFS plan. The HMO plan wants you to use its network of providers, but recognizes that sometimes enrollees want to choose their own provider. The POS plans have two rows for “In Network” and “Out of Network” benefits. In Network shows what you pay if you go to the plan’s providers; Out of Network shows what you pay if you decide not to go to the plan’s providers. Consumer-Driven Plans — Describes a wide range of approaches to give you more incentive to control the cost of either your health benefits or health care. You have greater freedom in spending health care dollars up to a designated amount, and you receive full coverage for in-network preventive care. In return, you assume significantly higher cost sharing expenses after you have used up the designated amount. The catastrophic limit is usually higher than those common in other plans. 35 Health Maintenance Organization (HMO) and Point of Service (POS) Plans How to read this chart: The table below highlights selected features that may help you narrow your choice of health plans. Always consult plan brochures before making your final decision. This chart does not show all of your possible out-of-pocket costs. Primary Care Specialist/Office Copay shows what you pay for each office visit to your primary care doctor and specialist. Contact your plan to find out what providers it considers specialists. Hospital per Stay Deductible is the amount you pay when you are admitted into a hospital. Plan Name – Location Alabama HealthSpring of Alabama, Inc. - Birmingham/Other areas Telephone Number Self only Self & family Self only Self & family 800/947-5093 DF1 DF2 $29.35 $114.91 Arizona Aetna Health Inc. - Phoenix/Tucson Areas Health Net of Arizona, Inc. - Maricopa/Pima/Other AZ counties Humana CoverageFirst (Consumer Driven Plan) - Phoenix PacifiCare Desert Region (AZ) - Maricopa, Pima County & Apache Junction 800/537-9384 800/289-2818 888/393-6765 800-531-3341 WQ1 A71 DB1 A31 WQ2 A72 DB2 A32 $12.99 $15.93 $10.27 $14.44 $35.69 $40.37 $23.61 $35.96 NCQA 1 NCQA 2 NCQA 2 California Aetna Health Inc. - Los Angeles and San Diego Areas Aetna HealthFund (Consumer Driven Plan) - Northern/Central Valley/Southern CA Blue Cross- HMO - Most of California Blue Shield of CA Access+ - Most of California Health Net of California - Most of California Kaiser Permanente - Northern California Kaiser Permanente - Southern California PacifiCare of California - Most of California UHP Healthcare - LA/Orange/San Bernardino Counties Universal Care - Southern California 800/537-9384 888/238-6240 800/235-8631 800/880-8086 800/522-0088 800/464-4000 800/464-4000 800-531-3341 800/544-0088 800/635-6668 2X1 221 M51 SJ1 LB1 591 621 CY1 C41 6Q1 2X2 222 M52 SJ2 LB2 592 622 CY2 C42 6Q2 $12.18 $14.56 $17.38 $15.17 $16.08 $17.77 $16.67 $13.49 $12.11 $12.39 $29.70 $33.49 $54.00 $37.64 $38.07 $49.95 $38.54 $31.31 $25.79 $32.71 NCQA 1 NCQA 1 NCQA 1 NCQA 1 NCQA 1 NCQA 1 JCAHO 1 NCQA 2 NCQA 2 Colorado Kaiser Permanente - Denver/Colorado Springs areas PacifiCare of Colorado - Denver/Colorado Springs/Ft.Collins 800/632-9700 800/877-9777 651 D61 652 D62 $16.09 $17.55 $41.88 $45.71 NCQA 1 NCQA 1 36 Accredited Enrollment Code Biweekly Premium Your Share Prescription Drugs — Generic, Brand Name, and Non-formulary shows what you pay for prescriptions when you use a plan pharmacy. You pay the Brand name amount if you or your doctor request the Brand name or if a Generic is not available. The figure in the Brand name/Non-formulary column is the copayment or coinsurance most commonly paid by members of this health plan for a Brand name formulary drug. If a nonformulary drug is prescribed and the cost to you is different than the Brand name, you pay the second amount if listed. Mail Order Discounts. If your plan has a Mail Order program and that program is superior to the purchase of medications at the pharmacy (e.g., you get a greater quantity or pay less through Mail Order), your plan’s response is “yes.” If the plan does not have a Mail Order program or it is not superior to its pharmacy benefit, the plan’s response is “no.” Member Survey Results — See page 3 for a description. Accredited — The National Committee for Quality Assurance (N); the Joint Commission on Accreditation of Healthcare Organizations (J); and/or URAC (U). See page 3 for details. A lower number means a better accreditation. Member Survey Results Getting needed care Overall plan satisfaction Getting care quickly Generic Plan Name Alabama HealthSpring of Alabama, Inc. $20/$25 $100/day x 5 $10 $25/$50 Yes h h h h Customer service * * Arizona Aetna Health Inc. Health Net of Arizona, Inc. Humana CoverageFirst - In-Network - Out-of-Network $20/$25 $15/$15 $20*/$35* 30%*/30%* $15/$30 $250/day x 3 $100/day x 5 $10 $10 $25/$40 $30/$45 Yes Yes No* No* Yes * f * * * h f f f f f f f f f f f * $100/day x 5* $10/$25* $25/$50* 30%* $10/$25+30%*$25/$50+30%* $200/ day x 5 $15 $35/$50 PacifiCare Desert Region (AZ & NV) California Aetna Health Inc. Aetna HealthFund Blue Cross- HMO Blue Shield of CA Access+ Health Net of California Kaiser Permanente Kaiser Permanente PacifiCare of California UHP Healthcare Universal Care - In-Network - Out-of-Network $20/$25 15%*/15%* 40%*/40%* $10/$10 $10/$10 $10/$10 $15/$15 $10/$10 $15/$30 $10/$10 $10/$10 $250/day x 3 15%* 40%* None None $100 None None $100/day x 3 $300 $300 $10 $10* $10* $5 $5 $10 $10 $10 $15 $10 $10 $25/$40 $25*/$40* $25*/$40* $10/50% $10/$25 $20/$35 $25 $25 $35/$50 $30/$50 $20/$30 Yes Yes* Yes* Yes Yes Yes No No Yes No Yes * f f * * * * * * h h h f f f f f * f * f f f * * * * f f * * * f * h * * * * h * * * f f f * * Colorado Kaiser Permanente PacifiCare of Colorado $15/$25 $10/$40 $250 $150/day x 5 $10 $10 $20 $35/$50 No Yes * f * * * h f * * f * * * See Brochure for details on patient’s payment responsibility. 37 Claims processing Brand Mail name/ order Nondiscount formulary How well doctors communicate Primary care / Specialist office copay Hospital per stay deductible Prescription Drugs h above average, * average, f below average Health Maintenance Organization (HMO) and Point of Service (POS) Plans How to read this chart: The table below highlights selected features that may help you narrow your choice of health plans. Always consult plan brochures before making your final decision. This chart does not show all of your possible out-of-pocket costs. Primary Care Specialist/Office Copay shows what you pay for each office visit to your primary care doctor and specialist. Contact your plan to find out what providers it considers specialists. Hospital per Stay Deductible is the amount you pay when you are admitted into a hospital. Plan Name – Location Connecticut Aetna HealthFund (Consumer Driven Plan) - All of Connecticut ConnectiCare - All of Connecticut Telephone Number Self only Self & family Self only Self & family 888/238-6240 800/251-7722 221 TE1 222 TE2 $14.56 $17.14 $33.49 $71.90 NCQA 1 District of Columbia Aetna Health Inc.-High- Washington, DC Area Aetna Health Inc.-Std -Washington, DC Area Aetna HealthFund (Consumer Driven Plan) - All of Washington D.C. CareFirst BlueChoice - Washington, D.C. Metro Area Kaiser Permanente - Washington, DC area M.D. IPA - Washington, DC area 800/537-9384 800/537-9384 888/238-6240 866/520-6099 301/468-6000 800/251-0956 JN1 JN4 221 2G1 E31 JP1 JN2 JN5 222 2G2 E32 JP2 $18.11 $11.90 $14.56 $38.32 $16.42 $16.52 $40.78 $27.84 $33.49 $81.51 $39.09 $39.64 NCQA 2 NCQA 2 NCQA 1 NCQA 1 NCQA 1 Florida Av-Med Health Plan - Broward, Dade and Palm Beach Capital Health Plan - Tallahassee area Humana CoverageFirst (Consumer Driven Plan) - Tampa Humana CoverageFirst (Consumer Driven Plan) - Jacksonville Humana CoverageFirst (Consumer Driven Plan) - South Florida Humana Medical Plan - South Florida JMH Health Plan - Broward-Dade counties Total Health Choice - Broward/Dade/Palm Beach Counties Vista Healthplan - South Florida Vista Healthplan - Pensacola area Vista Healthplan - Gainesville Vista Healthplan - Tallahassee Vista Healthplan of South Florida - Southern Florida 800/882-8633 850/383-3311 888/393-6765 888/393-6765 888/393-6765 888/393-6765 800/721-2993 800/213-1133 866/847-8235 866/847-8235 866/847-8235 866/847-8235 800/441-5501 ML1 EA1 MJ1 MQ1 QP1 EE1 J81 4A1 3N1 RK1 UL1 Y91 5E1 ML2 EA2 MJ2 MQ2 QP2 EE2 J82 4A2 3N2 RK2 UL2 Y92 5E2 $16.52 $16.71 $11.35 $11.89 $10.81 $16.94 $14.92 $13.14 $18.97 $17.85 $14.23 $13.40 $12.66 $76.56 $66.49 $26.10 $27.34 $24.86 $38.97 $36.93 $32.74 $119.06 $96.49 $37.98 $35.79 $34.81 URAC 1 NCQA 2 NCQA 1 38 Accredited Enrollment Code Biweekly Premium Your Share Prescription Drugs — Generic, Brand Name, and Non-formulary shows what you pay for prescriptions when you use a plan pharmacy. You pay the Brand name amount if you or your doctor request the Brand name or if a Generic is not available. The figure in the Brand name/Non-formulary column is the copayment or coinsurance most commonly paid by members of this health plan for a Brand name formulary drug. If a nonformulary drug is prescribed and the cost to you is different than the Brand name, you pay the second amount if listed. Mail Order Discounts. If your plan has a Mail Order program and that program is superior to the purchase of medications at the pharmacy (e.g., you get a greater quantity or pay less through Mail Order), your plan’s response is “yes.” If the plan does not have a Mail Order program or it is not superior to its pharmacy benefit, the plan’s response is “no.” Member Survey Results — See page 3 for a description. Accredited — The National Committee for Quality Assurance (N); the Joint Commission on Accreditation of Healthcare Organizations (J); and/or URAC (U). See page 3 for details. A lower number means a better accreditation. Member Survey Results Getting needed care Overall plan satisfaction Getting care quickly Plan Name Connecticut Aetna HealthFund ConnectiCare - In-Network - Out-of-Network 15%*/15%* 40%*/40%* $10/$10 15%* 40%* None $10* $10* $10 $25*/$40* $25*/$40* $20/$35 Yes* Yes* Yes h h h h h h District of Columbia Aetna Health Inc.-Std Aetna Health Inc.-High Aetna HealthFund CareFirst BlueChoice Kaiser Permanente M.D. IPA - In-Network - Out-of-Network $20/$25 $15/$20 15%*/15%* 40%*/40%* $20/$30 $10/$20 $10/$20 $250/day x 3 $150/day x 3 15%* 40%* $100/day x 5 $100 $100 $10 $10 $10* $10* $10 $10/$20Net $8 $25/$40 $25/$40 $25*/$40* $25*/$40* $25/$40 $20/$40 $20/$35 No No Yes* Yes* Yes Yes No f * * f f * f f * * f * f * h f * h f f * * f f * * * * * * Florida Av-Med Health Plan Capital Health Plan Humana CoverageFirst Humana CoverageFirst Humana CoverageFirst Humana Medical Plan JMH Health Plan Total Health Choice Vista Healthplan Vista Healthplan Vista Healthplan Vista Healthplan Vista Healthplan of South Florida - In-Network - Out-of-Network - In-Network - Out-of-Network - In-Network - Out-of-Network $15/$25 $10/$10 $20*/$35* 30%*/30%* $20*/$35* 30%*/30%* $20*/$35* 30%*/30%* $10/$20 $10/$10 $10/$10 $10/$20 $10/$20 $10/$20 $10/$20 $10/$20 $100/dayx5 $100 $15 $8 $30/$50 $25/$40 No No No* No* No* No* No* No* No No No Yes Yes Yes Yes Yes f f f f f f f f f f f f f f f f * f * h f h f * f * * h * h $100/day x 5* $10/$25* $25/$50* 30%* $10/$25+30%*$25/$50+30%* $100/day x 5* $10/$25* $25/$50* 30%* $10/$25+30%*$25/$50+30%* $100/day x 5* $10/$25* $25/$50* 30%* $10/$25+30%*$25/$50+30%* $100/day x 3 None $100 $100/day x 3 $100/day x 3 $100/day x 3 $100/day x 3 $100 x 3 days $5/$20 $5 $5 $10 $10 $10 $10 $10 $20/$40 50% $15 $20/$40 $20/$40 $20/$40 $20/$40 $20/$40 * See Brochure for details on patient’s payment responsibility. 39 Customer service Claims processing Brand Mail name/ order Generic Nondiscount formulary How well doctors communicate Primary care / Specialist office copay Hospital per stay deductible Prescription Drugs h above average, * average, f below average Health Maintenance Organization (HMO) and Point of Service (POS) Plans How to read this chart: The table below highlights selected features that may help you narrow your choice of health plans. Always consult plan brochures before making your final decision. This chart does not show all of your possible out-of-pocket costs. Primary Care Specialist/Office Copay shows what you pay for each office visit to your primary care doctor and specialist. Contact your plan to find out what providers it considers specialists. Hospital per Stay Deductible is the amount you pay when you are admitted into a hospital. Plan Name – Location Georgia Aetna Health Inc. - Atlanta and Athens Areas Aetna HealthFund (Consumer Driven Plan) - Atlanta Area Kaiser Permanente - Atlanta area Telephone Number Self only Self & family Self only Self & family 800/537-9384 888/238-6240 800/611-1811 2U1 221 F81 2U2 222 F82 $15.03 $14.56 $14.46 $36.26 $33.49 $36.71 NCQA 2 NCQA 1 Guam PacifiCare Asia Pacific-High -Guam/N.Mariana Islands/Belau PacifiCare Asia Pacific-Std - Guam/N.Mariana Islands/Belau 671/647-3526 671/647-3526 JK1 JK4 JK2 JK5 $16.27 $12.82 $52.80 $33.86 Hawaii HMSA - All of Hawaii Kaiser Permanente-High -Islands of Hawaii/Maui/Oahu/Kauai Kaiser Permanente-Std - Islands of Hawaii/Maui/Oahu/Kauai 808/948-6499 808/432-5955 808/432-5955 871 631 634 872 632 635 $15.18 $18.13 $14.57 $33.79 $38.97 $31.33 NCQA 1 NCQA 1 NCQA 1 Idaho Group Health Cooperative-High -Kootenai and Latah Group Health Cooperative-Std - Kootenai and Latah 888/901-4636 888/901-4636 VR1 VR4 VR2 VR5 $17.91 $15.52 $61.10 $35.71 NCQA 1 NCQA 1 40 Accredited Enrollment Code Biweekly Premium Your Share Prescription Drugs — Generic, Brand Name, and Non-formulary shows what you pay for prescriptions when you use a plan pharmacy. You pay the Brand name amount if you or your doctor request the Brand name or if a Generic is not available. The figure in the Brand name/Non-formulary column is the copayment or coinsurance most commonly paid by members of this health plan for a Brand name formulary drug. If a nonformulary drug is prescribed and the cost to you is different than the Brand name, you pay the second amount if listed. Mail Order Discounts. If your plan has a Mail Order program and that program is superior to the purchase of medications at the pharmacy (e.g., you get a greater quantity or pay less through Mail Order), your plan’s response is “yes.” If the plan does not have a Mail Order program or it is not superior to its pharmacy benefit, the plan’s response is “no.” Member Survey Results — See page 3 for a description. Accredited — The National Committee for Quality Assurance (N); the Joint Commission on Accreditation of Healthcare Organizations (J); and/or URAC (U). See page 3 for details. A lower number means a better accreditation. Member Survey Results Getting needed care Overall plan satisfaction Getting care quickly Plan Name Georgia Aetna Health Inc. Aetna HealthFund Kaiser Permanente - In-Network - Out-of-Network $20/$25 15%*/15%* 40%*/40%* $15/$15 $250/day x 3 15%* 40%* $250 $10 $10* $10* $10/$16 Com $25/$40 $25*/$40* $25*/$40* $10/$16 Yes Yes* Yes* No f * f f Customer service * h * * * h Guam PacifiCare Asia Pacific-High PacifiCare Asia Pacific-Std $10/$10 $15/$15 None $150 $5 $5 $5/$20 $5/$20 No No h h f f * * * * * * * * Hawaii HMSA Kaiser Permanente-High Kaiser Permanente-Std - In-Network - Out-of-Network $15/$15 30% sch +/30% sch + $10/$10 $15/$15 None None None None $5 $20/50% $5+20%+$20+20%+/50%+ $10 $10 $10 $10 Yes No Yes Yes h h h h * * h * * h * * h * * h * * Idaho Group Health Cooperative-High Group Health Cooperative-Std $15/$15 $20+20%/$20+20% $200/day x 3 $200/day x 3 $15 $20 $25/$50 $30/$60 Yes Yes * * * * h h * * * * * * * See Brochure for details on patient’s payment responsibility. 41 Claims processing Brand Mail name/ order Generic Nondiscount formulary How well doctors communicate Primary care / Specialist office copay Hospital per stay deductible Prescription Drugs h above average, * average, f below average f h Health Maintenance Organization (HMO) and Point of Service (POS) Plans How to read this chart: The table below highlights selected features that may help you narrow your choice of health plans. Always consult plan brochures before making your final decision. This chart does not show all of your possible out-of-pocket costs. Primary Care Specialist/Office Copay shows what you pay for each office visit to your primary care doctor and specialist. Contact your plan to find out what providers it considers specialists. Hospital per Stay Deductible is the amount you pay when you are admitted into a hospital. Plan Name – Location Illinois Aetna HealthFund (Consumer Driven Plan) - Chicago Area BlueCHOICE - Madison and St. Clair counties Group Health Plan - Southern/Metro East/Central Health Alliance HMO - Central/E.Central/N.West/South/West IL Humana CoverageFirst (Consumer Driven Plan) - Chicago Humana Health Plan Inc.-High -Chicago area Humana Health Plan Inc.-Std - Chicago area John Deere Health Plan - Bloomingtn/Moline/Peoria/RockIsld Mercy Health Plans/Premier Health Plans - Southwest Illinois OSF HealthPlans - Central/Central-Northwestern Illinois PersonalCare's HMO - Central Illinois Unicare HMO - Chicagoland Area Union Health Service - Chicago area Telephone Number Self only Self & family Self only Self & family 888/238-6240 800/634-4395 800/755-3901 800/851-3379 888/393-6765 888/393-6765 888/393-6765 800/247-9110 800/327-0763 800/673-5222 800/431-1211 888/234-8855 312/829-4224 221 9G1 MM1 FX1 MW1 751 754 YH1 7M1 9F1 GE1 171 761 222 9G2 MM2 FX2 MW2 752 755 YH2 7M2 9F2 GE2 172 762 $14.56 $17.29 $54.20 $26.08 $8.65 $17.55 $13.45 $16.00 $50.22 $14.71 $15.49 $16.46 $13.92 $33.49 $37.43 $99.51 $68.25 $19.89 $40.36 $30.94 $39.20 $90.94 $38.69 $39.84 $71.04 $34.51 NCQA 1 NCQA 1 NCQA 1 NCQA 1 NCQA 1 URAC 1 NCQA 1 42 Accredited Enrollment Code Biweekly Premium Your Share Prescription Drugs — Generic, Brand Name, and Non-formulary shows what you pay for prescriptions when you use a plan pharmacy. You pay the Brand name amount if you or your doctor request the Brand name or if a Generic is not available. The figure in the Brand name/Non-formulary column is the copayment or coinsurance most commonly paid by members of this health plan for a Brand name formulary drug. If a nonformulary drug is prescribed and the cost to you is different than the Brand name, you pay the second amount if listed. Mail Order Discounts. If your plan has a Mail Order program and that program is superior to the purchase of medications at the pharmacy (e.g., you get a greater quantity or pay less through Mail Order), your plan’s response is “yes.” If the plan does not have a Mail Order program or it is not superior to its pharmacy benefit, the plan’s response is “no.” Member Survey Results — See page 3 for a description. Accredited — The National Committee for Quality Assurance (N); the Joint Commission on Accreditation of Healthcare Organizations (J); and/or URAC (U). See page 3 for details. A lower number means a better accreditation. Member Survey Results Getting needed care Overall plan satisfaction Getting care quickly Plan Name Illinois Aetna HealthFund BlueCHOICE Group Health Plan Health Alliance HMO Humana CoverageFirst Humana Health Plan Inc.-High Humana Health Plan Inc.-Std John Deere Health Plan Mercy Health Plans/Premier OSF HealthPlans PersonalCare's HMO Unicare HMO Union Health Service - In-Network - Out-of-Network - In-Network - Out-of-Network - In-Network - Out-of-Network 15%*/15%* 40%*/40%* $10/$10 $10/$20 $15/$15 $20*/$35* 30%*/30%* $10/$20 $15/$25 $15/$15 $10/$20 30%/30% $20/$20 $20/$20 $15/$15 $10/$10 15%* 40%* None $100 $100 $10* $10* $7 $10 $10 $25*/$40* $25*/$40* $12/$25 $20/$35 $20/$40 Yes* Yes* Yes Yes No No* No* No No Yes Yes No No No No No * * h * h * * f f h h * h * * * h * h h f * * * * h * * f f h * * * * f f h * h * f * * h h * * h * h * * * * * * * * h $100/day x 5* $10/$25* $25/$50* 30%* $10/$25+30%*$25/$50+30%* $100/day x 3 $250/day x 3 $100/day x 5 None None $500 $100/day x 5 None None $5/$15 $10/$25 $10 $10 N/A $10 $10 $5 $15 $15/$35 $25/$45 $20/$35 $20/$35 N/A $20/$40 $20/$50 $15/$25 $15/$15 * See Brochure for details on patient’s payment responsibility. 43 Customer service Claims processing Brand Mail name/ order Generic Nondiscount formulary How well doctors communicate Primary care / Specialist office copay Hospital per stay deductible Prescription Drugs h above average, * average, f below average Health Maintenance Organization (HMO) and Point of Service (POS) Plans How to read this chart: The table below highlights selected features that may help you narrow your choice of health plans. Always consult plan brochures before making your final decision. This chart does not show all of your possible out-of-pocket costs. Primary Care Specialist/Office Copay shows what you pay for each office visit to your primary care doctor and specialist. Contact your plan to find out what providers it considers specialists. Hospital per Stay Deductible is the amount you pay when you are admitted into a hospital. Plan Name – Location Indiana Advantage Health Plan, Inc. - Most of Indiana Aetna Health Inc. - Southeastern Indiana Aetna HealthFund (Consumer Driven Plan) - Lake and Porter Counties Arnett HMO - Lafayette area Health Alliance HMO - Fountain/Vermillion/Warren Counties Humana CoverageFirst (Consumer Driven Plan) - Southern Indiana Humana CoverageFirst (Consumer Driven Plan) - Lake/Porter/LaPorte Counties Humana Health Plan - Southern Indiana Humana Health Plan Inc.-High -Lake/Porter/LaPorte Counties Humana Health Plan Inc.-Std - Lake/Porter/LaPorte Counties M*Plan - Indiana Metropolitan areas Physicians Health Plan of Northern Indiana - Northeast Indiana Unicare HMO - Lake/Porter Counties Telephone Number Self only Self & family Self only Self & family 800/553-8933 800/537-9384 888/238-6240 765/448-7440 800/851-3379 888/393-6765 888/393-6765 888/393-6765 888/393-6765 888/393-6765 317/571-5320 260/432-6690 888/234-8855 6Y1 RD1 221 G21 FX1 BM1 MW1 D21 751 754 IN1 DQ1 171 6Y2 RD2 222 G22 FX2 BM2 MW2 D22 752 755 IN2 DQ2 172 $25.70 $16.99 $14.56 $14.40 $26.08 $12.97 $8.65 $34.75 $17.55 $13.45 $44.93 $17.41 $16.46 $69.73 $43.96 $33.49 $37.43 $68.25 $29.83 $19.89 $82.41 $40.36 $30.94 $104.92 $39.09 $71.04 NCQA 6 NCQA 1 NCQA 1 NCQA 1 NCQA 2 NCQA 1 NCQA 1 Iowa Avera Health Plans - Northwestern Iowa Coventry Health Care of Iowa - Central Iowa/Cedar Rapids/Sioux City Health Alliance HMO - Central and Eastern Iowa John Deere Health Plan - Central/Eastern Iowa Sioux Valley Health Plan-High -Northwestern Iowa Sioux Valley Health Plan-Std - Northwestern Iowa 888/322-2115 800/257-4692 800/851-3379 800/247-9110 800/752-5863 800/752-5863 AV1 SV1 FX1 YH1 AU1 AU4 AV2 SV2 FX2 YH2 AU2 AU5 $16.29 $15.09 $26.08 $16.00 $70.34 $38.00 $38.03 $40.75 $68.25 $39.20 $164.13 $89.71 NCQA 1 NCQA 1 NCQA 1 44 Accredited Enrollment Code Biweekly Premium Your Share Prescription Drugs — Generic, Brand Name, and Non-formulary shows what you pay for prescriptions when you use a plan pharmacy. You pay the Brand name amount if you or your doctor request the Brand name or if a Generic is not available. The figure in the Brand name/Non-formulary column is the copayment or coinsurance most commonly paid by members of this health plan for a Brand name formulary drug. If a nonformulary drug is prescribed and the cost to you is different than the Brand name, you pay the second amount if listed. Mail Order Discounts. If your plan has a Mail Order program and that program is superior to the purchase of medications at the pharmacy (e.g., you get a greater quantity or pay less through Mail Order), your plan’s response is “yes.” If the plan does not have a Mail Order program or it is not superior to its pharmacy benefit, the plan’s response is “no.” Member Survey Results — See page 3 for a description. Accredited — The National Committee for Quality Assurance (N); the Joint Commission on Accreditation of Healthcare Organizations (J); and/or URAC (U). See page 3 for details. A lower number means a better accreditation. Member Survey Results Getting needed care Overall plan satisfaction Getting care quickly Plan Name Indiana Advantage Health Plan, Inc. Aetna Health Inc. Aetna HealthFund Arnett HMO Health Alliance HMO Humana CoverageFirst Humana CoverageFirst Humana Health Plan Humana Health Plan Inc.-High Humana Health Plan Inc.-Std M*Plan Physicians Health Plan of Northern Indiana Unicare HMO - In-Network - Out-of-Network - In-Network - Out-of-Network - In-Network - Out-of-Network $15/$30 $20/$25 15%*/15%* 40%*/40%* $10/$10 $15/$15 $20*/$35* 30%*/30%* $20*/$35* 30%*/30%* $15/$25 $10/$20 $15/$25 $15/$30 $15/$15 $15/$15 $400x2/Yr $250/day x 3 15%* 40%* None $100 $10 $10 $10* $10* $10 $10 $30/$50 $25/$40 $25*/$40* $25*/$40* $20/$40 $20/$40 Yes Yes Yes* Yes* No No No* No* No* No* No No No Yes No No f * * * * h h * Customer service * * h h h * h h * * h * $100/day x 5* $10/$25* $25/$50* 30%* $10/$25+30%*$25/$50+30%* $100/day x 5* $10/$25* $25/$50* 30%* $10/$25+30%*$25/$50+30%* $250/day x 3 $100/day x 3 $250/day x 3 $250 20% None $10/$25 $5/$15 $10/$25 $10/$20 $10 $5 $25/$45 $15/$35 $25/$45 $30/$50 $20/$40 $15/$25 * * * * h * * f f * h f * * * * h f * * * * h * * f f f h f Iowa Avera Health Plans Coventry Health Care of Iowa Health Alliance HMO John Deere Health Plan Sioux Valley Health Plan Sioux Valley Health Plan - In-Network - Out-of-Network - In-Network - Out-of-Network $10/$15 $10/$10 $15/$15 $15/$15 $20/$30 40%/40% $25/$25 40%/40% $100/dayx3 None $100 $100/day x 5 $100/day x 5 40% $100/day x 5 40% $10 $5 $10 $10 $15 N/A $15 N/A $20 $15/$30 $20/$40 $20/$35 $30/$50 N/A $30/$50 N/A No No No Yes No No No No f h h h * h h h h * * * f * h f h h * See Brochure for details on patient’s payment responsibility. 45 Claims processing Brand Mail name/ order Generic Nondiscount formulary How well doctors communicate Primary care / Specialist office copay Hospital per stay deductible Prescription Drugs h above average, * average, f below average * f h h * f f * h f Health Maintenance Organization (HMO) and Point of Service (POS) Plans How to read this chart: The table below highlights selected features that may help you narrow your choice of health plans. Always consult plan brochures before making your final decision. This chart does not show all of your possible out-of-pocket costs. Primary Care Specialist/Office Copay shows what you pay for each office visit to your primary care doctor and specialist. Contact your plan to find out what providers it considers specialists. Hospital per Stay Deductible is the amount you pay when you are admitted into a hospital. Plan Name – Location Kansas Coventry Health Care of Kansas - Kansas City - Kansas City area Coventry Health Care of Kansas - Wichita/Salina areas Humana CoverageFirst (Consumer Driven Plan) - Kansas City Humana Health Plan, Inc.-High -Kansas City area Humana Health Plan, Inc.-Std - Kansas City area Preferred Plus of Kansas - S. Central Area Telephone Number Self only Self & family Self only Self & family 800/969-3343 800/664-9251 888/393-6765 888/393-6765 888/393-6765 800/660-8114 HA1 7W1 PH1 MS1 MS4 VA1 HA2 7W2 PH2 MS2 MS5 VA2 $16.98 $14.89 $8.65 $27.39 $13.83 $68.95 $57.72 $38.42 $19.89 $65.52 $31.80 $237.52 URAC 1 URAC 1 JCAHO 1 Kentucky Humana CoverageFirst (Consumer Driven Plan) - Louisville Humana Health Plan - Louisville area United Healthcare of Ohio, Inc. - Northern Kentucky 888/393-6765 888/393-6765 800/231-2918 BM1 D21 3U1 BM2 D22 3U2 $12.97 $34.75 $54.17 $29.83 $82.41 $127.11 NCQA 2 NCQA 1 Louisiana Coventry Healthcare Louisiana - New Orleans area Coventry Healthcare Louisiana - Baton Rouge area Vantage Health Plan - Monroe/Shreveport/Alexandria Areas 800/341-6613 800/341-6613 888/823-1910 BJ1 JA1 MV1 BJ2 JA2 MV2 $13.76 $27.17 $34.71 $31.96 $68.83 $135.75 Maryland Aetna Health Inc.-High -Northern/Central/Southern Maryland Aetna Health Inc.-Std - Northern/Central/Southern Maryland Aetna HealthFund (Consumer Driven Plan) - All of Maryland CareFirst BlueChoice - All of Maryland Kaiser Permanente - Baltimore/Washington, DC areas M.D. IPA - All of Maryland 800/537-9384 800/537-9384 888/238-6240 866/520-6099 301/468-6000 800/251-0956 JN1 JN4 221 2G1 E31 JP1 JN2 JN5 222 2G2 E32 JP2 $18.11 $11.90 $14.56 $38.32 $16.42 $16.52 $40.78 $27.84 $33.49 $81.51 $39.09 $39.64 NCQA 2 NCQA 2 NCQA 1 NCQA 1 NCQA 1 46 Accredited Enrollment Code Biweekly Premium Your Share Prescription Drugs — Generic, Brand Name, and Non-formulary shows what you pay for prescriptions when you use a plan pharmacy. You pay the Brand name amount if you or your doctor request the Brand name or if a Generic is not available. The figure in the Brand name/Non-formulary column is the copayment or coinsurance most commonly paid by members of this health plan for a Brand name formulary drug. If a nonformulary drug is prescribed and the cost to you is different than the Brand name, you pay the second amount if listed. Mail Order Discounts. If your plan has a Mail Order program and that program is superior to the purchase of medications at the pharmacy (e.g., you get a greater quantity or pay less through Mail Order), your plan’s response is “yes.” If the plan does not have a Mail Order program or it is not superior to its pharmacy benefit, the plan’s response is “no.” Member Survey Results — See page 3 for a description. Accredited — The National Committee for Quality Assurance (N); the Joint Commission on Accreditation of Healthcare Organizations (J); and/or URAC (U). See page 3 for details. A lower number means a better accreditation. Member Survey Results Getting needed care Overall plan satisfaction Getting care quickly Plan Name Kansas Coventry Health Care of Kansas - Kansas City Coventry Health Care of Kansas Humana CoverageFirst Humana Health Plan, Inc.-High Humana Health Plan, Inc.-Std Preferred Plus of Kansas - In-Network - Out-of-Network $15/$15 $15/$15 $20*/$35* 30%*/30%* $10/$20 $15/$25 $10/$10 $100/day x 3 $100/day x 3 $10 $5 $20/$50 $15/$45 Yes Yes No* No* No No Yes f f * * * * h h Customer service f f $100/day x 5* $10/$25* $25/$50* 30%* $10/$25+30%*$25/$50+30%* $100/day x 3 $250/day x 3 $50/day x 10 $5/$20 $10/$25 $5 $20/$40 $25/$45 $15 f f * * * * f f * * Kentucky Humana CoverageFirst Humana Health Plan United Healthcare of Ohio, Inc. - In-Network - Out-of-Network $20*/$35* 30%*/30%* $15/$25 $15/$15 $100/day x 5* $10/$25* $25/$50* 30%* $10/$25+30%*$25/$50+30%* $250/day x 3 $250 $10/$25 $10 $25/$45 $15/$30 No* No* No Yes * * * h * * * h * * * * Louisiana Coventry Healthcare Louisiana Coventry Healthcare Louisiana Vantage Health Plan $15/$15 $15/$15 $15/$15 $100/day x 3 $100/day x 3 $250 $10 $10 $10 $20/$45 $20/$45 $20/$35 Yes Yes Yes f f * * * * h h * * * * Maryland Aetna Health Inc.-High Aetna Health Inc.-Std Aetna HealthFund CareFirst BlueChoice Kaiser Permanente M.D. IPA - In-Network - Out-of-Network $15/$20 $20/$25 15%*/15%* 40%*/40%* $20/$30 $10/$20 $10/$20 $150/day x 3 $250/day x 3 15%* 40%* $100/day x 5 $100 $100 $10 $10 $10* $10* $10 $10/$20Net $8 $25/$40 $25/$40 $25*/$40* $25*/$40* $25/$40 $20/$40 $20/$35 No No Yes* Yes* Yes Yes No f * * f f * f f * * f * f * h f * h f f * * f f * * * * * * * See Brochure for details on patient’s payment responsibility. 47 Claims processing Brand Mail name/ order Generic Nondiscount formulary How well doctors communicate Primary care / Specialist office copay Hospital per stay deductible Prescription Drugs h above average, * average, f below average * * f f Health Maintenance Organization (HMO) and Point of Service (POS) Plans How to read this chart: The table below highlights selected features that may help you narrow your choice of health plans. Always consult plan brochures before making your final decision. This chart does not show all of your possible out-of-pocket costs. Primary Care Specialist/Office Copay shows what you pay for each office visit to your primary care doctor and specialist. Contact your plan to find out what providers it considers specialists. Hospital per Stay Deductible is the amount you pay when you are admitted into a hospital. Plan Name – Location Massachusetts Blue Chip, Coord Hlth Partners - Southeastern Massachusetts ConnectiCare - Counties Hampden, Hampshire, Franklin Fallon Community Health Plan - Central/Eastern Massachusetts Telephone Number Self only Self & family Self only Self & family 401/459-5500 800/251-7722 800/868-5200 DA1 TE1 JV1 DA2 TE2 JV2 $39.52 $17.14 $35.34 $141.05 $71.90 $107.11 NCQA 1 NCQA 1 NCQA 1 Michigan Bluecare Network of MI - Midland County Area Bluecare Network of MI - Kalamazoo County Area Bluecare Network of MI - Genesee County Area Bluecare Network of MI - Kent County Area Bluecare Network of MI - Mid Michigan Bluecare Network of MI - Southeast MI Grand Valley Health Plan - Grand Rapids area Health Alliance Plan - Southeastern Michigan/Flint area HealthPlus MI - Flint/Saginaw areas M-Care - Southeastern Michigan and Flint area OmniCare - Southeastern Michigan Total Health Care - Greater Detroit/Flint areas 800/662-6667 800/662-6667 800/662-6667 800/662-6667 800/662-6667 800/662-6667 616/949-2410 800/422-4641 800/332-9161 800/658-8878 800/477-6664 800/826-2862 K51 KF1 KN1 KR1 LN1 LX1 RL1 521 X51 EG1 KA1 N21 K52 KF2 KN2 KR2 LN2 LX2 RL2 522 X52 EG2 KA2 N22 $17.83 $56.00 $25.19 $49.54 $66.21 $13.45 $16.85 $15.13 $33.57 14.25 14.23 13.02 $116.47 $230.60 $143.97 $230.00 $177.44 $40.23 $93.42 $40.09 $76.84 $37.76 $35.02 $31.97 NCQA 1 NCQA 1 NCQA 1 NCQA 1 NCQA 1 NCQA 1 NCQA 1 NCQA 1 NCQA 1 NCQA 1 NCQA 3 Minnesota Avera Health Plans - Southwestern Minnesota HealthPartners Classic-High -Minneapolis/St. Paul/St.Cloud HealthPartners Open Access-Basic - Minneapolis/St. Paul/St.Cloud HealthPartners Primary Clinic Plan - Minneapolis/St. Paul/St. Cloud 888/322-2115 952-883-5000 952-883-5000 952-883-5000 AV1 531 534 HQ1 AV2 532 535 HQ2 $16.29 $50.11 $20.64 $96.57 $38.03 $137.10 $66.36 $248.60 NCQA 1 NCQA 1 NCQA 1 48 Accredited Enrollment Code Biweekly Premium Your Share Prescription Drugs — Generic, Brand Name, and Non-formulary shows what you pay for prescriptions when you use a plan pharmacy. You pay the Brand name amount if you or your doctor request the Brand name or if a Generic is not available. The figure in the Brand name/Non-formulary column is the copayment or coinsurance most commonly paid by members of this health plan for a Brand name formulary drug. If a nonformulary drug is prescribed and the cost to you is different than the Brand name, you pay the second amount if listed. Mail Order Discounts. If your plan has a Mail Order program and that program is superior to the purchase of medications at the pharmacy (e.g., you get a greater quantity or pay less through Mail Order), your plan’s response is “yes.” If the plan does not have a Mail Order program or it is not superior to its pharmacy benefit, the plan’s response is “no.” Member Survey Results — See page 3 for a description. Accredited — The National Committee for Quality Assurance (N); the Joint Commission on Accreditation of Healthcare Organizations (J); and/or URAC (U). See page 3 for details. A lower number means a better accreditation. Member Survey Results Getting needed care Overall plan satisfaction Getting care quickly Plan Name Massachusetts Blue Chip, Coord Hlth Partners ConnectiCare Fallon Community Health Plan - In-Network - Out-of-Network $15/$25 30%/30% $10/$10 $10/$10 $500 None None $100 $7 $25/$40 Yes $40+20%$40+20%/$40+20% No $10 $5 $20/$35 $20/$40 Yes Yes f h * h h * h h h h h * Customer service * h * Michigan Bluecare Network of MI Bluecare Network of MI Bluecare Network of MI Bluecare Network of MI Bluecare Network of MI Bluecare Network of MI Grand Valley Health Plan Health Alliance Plan HealthPlus MI M-Care OmniCare Total Health Care $10/$10 $10/$10 $10/$10 $10/$10 $10/$10 $10/$10 $10/$10 $10/$10 $10/$10 $10/$10 $10/$10 $10/$10 Nothing Nothing Nothing Nothing Nothing Nothing None None None None None None $5 $5 $5 $5 $5 $5 $5 $10 $10 $10 $5 Nothing $20 $20 $20 $20 $20 $20 $5 $20 $20 $20/$30 $10/$25 Nothing Yes Yes Yes Yes Yes Yes No Yes Yes No Yes No * * * * * * h * h * f f f f f f f f * * h * f f * * * * * * h f h * f f f f f f f f * * h * f * f f f f f f h f h * * * * * * * * * h * h * * f Minnesota Avera Health Plans HealthPartners Classic-High HealthPartners Open Access-Basic HealthPartners Primary Clinic Plan $10/$15 $15/$15 $15/$15 $20/$20 $100/dayx3 $100 $100 $200 $10 $12 $10 $12 $20 $12/$24 $10/$35 $12/$24 Yes No No No f f f * * * * * * * * * f f f * * * 49 Claims processing Brand Mail name/ order Generic Nondiscount formulary How well doctors communicate Primary care / Specialist office copay Hospital per stay deductible Prescription Drugs h above average, * average, f below average * h * Health Maintenance Organization (HMO) and Point of Service (POS) Plans How to read this chart: The table below highlights selected features that may help you narrow your choice of health plans. Always consult plan brochures before making your final decision. This chart does not show all of your possible out-of-pocket costs. Primary Care Specialist/Office Copay shows what you pay for each office visit to your primary care doctor and specialist. Contact your plan to find out what providers it considers specialists. Hospital per Stay Deductible is the amount you pay when you are admitted into a hospital. Plan Name – Location Missouri BlueCHOICE - St Louis/Central/SW areas Coventry Health Care of Kansas - Kansas City - Kansas City area Group Health Plan - St. Louis area Humana CoverageFirst (Consumer Driven Plan) - Kansas City Humana Health Plan, Inc.-High -Kansas City area Humana Health Plan, Inc.-Std - Kansas City area Mercy Health Plans/Premier Health Plans - East/Central/Southwest Missouri Telephone Number Self only Self & family Self only Self & family 800/634-4395 800-969-3343 800/755-3901 888/393-6765 888/393-6765 888/393-6765 800/327-0763 9G1 HA1 MM1 PH1 MS1 MS4 7M1 9G2 HA2 MM2 PH2 MS2 MS5 7M2 $17.29 $14.89 $54.20 $8.65 $27.39 $13.83 $50.22 $37.43 $38.42 $99.51 $19.89 $65.52 $31.80 $90.94 NCQA 1 URAC 1 URAC 1 URAC 1 Montana New West Health Services - Most of Montana 800/290-3657 NV1 NV2 $17.24 $38.36 Nevada Aetna Health Inc. - Las Vegas Area Health Plan of Nevada - Las Vegas area PacifiCare Desert Region (NV) - Las Vegas/Clark County 800/537-9384 800/777-1840 800-531-3341 Y11 NM1 K91 Y12 NM2 K92 $15.13 $10.35 $14.07 $37.68 $26.49 $31.95 NCQA 2 NCQA 2 New Jersey Aetna Health Inc. - All of New Jersey Aetna HealthFund (Consumer Driven Plan) - All of New Jersey AmeriHealth HMO - All of New Jersey GHI Health Plan-High -Northern New Jersey 800/537-9384 888/238-6240 800/454-7651 212/501-4444 P31 221 FK1 801 P32 222 FK2 802 $17.88 $14.56 $17.01 $41.85 $56.31 $33.49 $40.62 $135.80 NCQA 1 URAC 1 NCQA 1 New Mexico Cimarron Health Plan - All of New Mexico Lovelace Health Plan - All of New Mexico Presbyterian Health Plan - All NM counties except Otero & S. Eddy 800/473-0391 800/244-6224 800/356-2219 PX1 Q11 P21 PX2 Q12 P22 $18.03 $17.31 $16.24 $93.71 $50.57 $49.33 NCQA 2 NCQA 1 NCQA 2 50 Accredited Enrollment Code Biweekly Premium Your Share Prescription Drugs — Generic, Brand Name, and Non-formulary shows what you pay for prescriptions when you use a plan pharmacy. You pay the Brand name amount if you or your doctor request the Brand name or if a Generic is not available. The figure in the Brand name/Non-formulary column is the copayment or coinsurance most commonly paid by members of this health plan for a Brand name formulary drug. If a nonformulary drug is prescribed and the cost to you is different than the Brand name, you pay the second amount if listed. Mail Order Discounts. If your plan has a Mail Order program and that program is superior to the purchase of medications at the pharmacy (e.g., you get a greater quantity or pay less through Mail Order), your plan’s response is “yes.” If the plan does not have a Mail Order program or it is not superior to its pharmacy benefit, the plan’s response is “no.” Member Survey Results — See page 3 for a description. Accredited — The National Committee for Quality Assurance (N); the Joint Commission on Accreditation of Healthcare Organizations (J); and/or URAC (U). See page 3 for details. A lower number means a better accreditation. Member Survey Results Getting needed care Overall plan satisfaction Getting care quickly Plan Name Missouri BlueCHOICE Coventry Health Care of Kansas - Kansas City Group Health Plan Humana CoverageFirst Humana Health Plan, Inc.-High Humana Health Plan, Inc.-Std Mercy Health Plans/Premier - In-Network - Out-of-Network - In-Network - Out-of-Network $10/$10 $15/$15 $10/$20 $20*/$35* 30%*/30%* $10/$20 $15/$25 $10/$20 30%/30% None $100/day x 3 $100 $7 $10 $10 $12/$25 $20/$50 $20/$35 Yes Yes Yes No* No* No No Yes No * f * h * * h * * * h * Customer service * f * $100/day x 5* $10/$25* $25/$50* 30%* $10/$25+30%*$25/$50+30%* $100/day x 3 $250/day x 3 None None $5/$20 $10/$25 $10 N/A $20/$40 $25/$45 $20/$35 N/A f f * * * h * * h f f h * * h Montana New West Health Plan $15/$15 $100 $10 $20/$40 Yes Nevada Aetna Health Inc. Health Plan of Nevada PacifiCare Desert Region (AZ & NV) $20/$25 $10/$10 $15/$30 $250/day x 3 $100 $200/ day x 5 $10 $5 $15 $25/$40 $20/$35 $35/$50 Yes Yes Yes f * f f f f f f f * f * New Jersey Aetna Health Inc. Aetna HealthFund AmeriHealth HMO GHI Health Plan - In-Network - Out-of-Network - In-Network - Out-of-Network $20/$25 15%*/15%* 40%*/40%* $30/$35 $15/$15 50% of sch./50% of sch. $250/day x 3 15%* 40%* $200/day x 3 None None $10 $10* $10* $15 $10 N/A $25/$40 $25*/$40* $25*/$40* $40/50% $20/$50 N/A Yes Yes* Yes* Yes Yes No f * * * * * * * * f f * * * * * * * New Mexico Cimarron Health Plan Lovelace Health Plan Presbyterian Health Plan $10/$10 $15/$25 $10/$10 $100 $250 None $5 $7 $7 $15/$30 $15/$35 $17/$34 Yes Yes Yes f * * f f f f f f f * * f * * f * * * See Brochure for details on patient’s payment responsibility. 51 Claims processing Brand Mail name/ order Generic Nondiscount formulary How well doctors communicate Primary care / Specialist office copay Hospital per stay deductible Prescription Drugs h above average, * average, f below average * * * f f h Health Maintenance Organization (HMO) and Point of Service (POS) Plans How to read this chart: The table below highlights selected features that may help you narrow your choice of health plans. Always consult plan brochures before making your final decision. This chart does not show all of your possible out-of-pocket costs. Primary Care Specialist/Office Copay shows what you pay for each office visit to your primary care doctor and specialist. Contact your plan to find out what providers it considers specialists. Hospital per Stay Deductible is the amount you pay when you are admitted into a hospital. Plan Name – Location New York Aetna Health Inc. - NYC Area and Dutchess/Sullivan/Ulster Aetna HealthFund (Consumer Driven Plan) - New York City Area Blue Choice - Rochester area Capital District Physicians' Health Plan - North /Central New York Capital District Physicians' Health Plan - Hudson Valley area Capital District Physicians' Health Plan - Capital District area GHI Health Plan-High -All of New York GHI Health Plan-Std - NYC/Brnx/Kings/Queen/Rich/Nass/Suff/Rock/Westche GHI HMO Select - Brnx/Brklyn/Manhat/Queen/Richmon/Westche GHI HMO Select - Capital/Hudson Valley Regions HIP of Greater New York-High -New York City area HIP of Greater New York-Std - New York City area HMO Blue - Utica/Rome/Central New York areas HMOBlue-CNY - Syracuse/Binghamton/Elmira areas Independent Health Assoc - Western New York MVP Health Care - Eastern Region MVP Health Care - Central Region MVP Health Care - Mid-Hudson Region Preferred Care - Rochester area Univera Healthcare - Western New York (Southern Counties) Univera Healthcare - Western New York (Northern Counties) Vytra Health Plans - Queens/Nassau/Suffolk Counties Telephone Number Self only Self & family Self only Self & family 800/537-9384 888/238-6240 800/462-0108 518/641-3700 518/641-3700 518/641-3700 212/501-4444 212/501-4444 877/244-4466 877/244-4466 800/HIP-TALK 800/HIP-TALK 800/722-7884 800/828-2887 800/453-1910 888/687-6277 888/687-6277 888/687-6277 800/950-3224 716/847-0881 716/847-0881 800/406-0806 JC1 221 MK1 PW1 QB1 SG1 801 804 6V1 X41 511 514 AH1 EB1 QA1 GA1 M91 MX1 GV1 KQ1 Q81 J61 JC2 222 MK2 PW2 QB2 SG2 802 805 6V2 X42 512 515 AH2 EB2 QA2 GA2 M92 MX2 GV2 KQ2 Q82 J62 $18.18 $14.56 $13.51 $17.65 $17.13 $16.61 $41.85 $17.87 $32.98 $21.62 $16.44 $13.16 $67.71 $40.15 $11.82 $13.92 $15.78 $16.21 $13.45 $16.28 $12.84 $32.21 $70.43 $33.49 $33.86 $74.43 $63.04 $50.91 $135.80 $70.08 $110.89 $96.47 $81.91 $36.84 $211.76 $97.34 $33.09 $35.94 $40.75 $44.97 $35.91 $56.15 $36.41 $133.20 NCQA 1 NCQA 2 NCQA 1 NCQA 1 NCQA 1 URAC 1 URAC 1 NCQA 3 NCQA 3 NCQA 2 NCQA 2 NCQA 1 NCQA 1 NCQA 1 NCQA 1 NCQA 1 NCQA 1 NCQA 1 NCQA 1 NCQA 1 52 Accredited Enrollment Code Biweekly Premium Your Share Prescription Drugs — Generic, Brand Name, and Non-formulary shows what you pay for prescriptions when you use a plan pharmacy. You pay the Brand name amount if you or your doctor request the Brand name or if a Generic is not available. The figure in the Brand name/Non-formulary column is the copayment or coinsurance most commonly paid by members of this health plan for a Brand name formulary drug. If a nonformulary drug is prescribed and the cost to you is different than the Brand name, you pay the second amount if listed. Mail Order Discounts. If your plan has a Mail Order program and that program is superior to the purchase of medications at the pharmacy (e.g., you get a greater quantity or pay less through Mail Order), your plan’s response is “yes.” If the plan does not have a Mail Order program or it is not superior to its pharmacy benefit, the plan’s response is “no.” Member Survey Results — See page 3 for a description. Accredited — The National Committee for Quality Assurance (N); the Joint Commission on Accreditation of Healthcare Organizations (J); and/or URAC (U). See page 3 for details. A lower number means a better accreditation. Member Survey Results Getting needed care Overall plan satisfaction Getting care quickly Plan Name New York Aetna Health Inc. Aetna HealthFund Blue Choice Capital District Physicians' Health Plan Capital District Physicians' Health Plan Capital District Physicians' Health Plan GHI Health Plan GHI Health Plan-Std GHI HMO Select GHI HMO Select HIP of Greater New York-High HIP of Greater New York-Std HMO Blue HMOBlue-CNY Independent Health Assoc MVP Health Care MVP Health Care MVP Health Care Preferred Care Univera Healthcare Univera Healthcare Vytra Health Plans - In-Network - Out-of-Network - In-Network - Out-of-Network $20/$25 15%*/15%* 40%*/40%* $15/$15 $15/$15 $15/$15 $15/$15 $15/$15 50% of sch./50% of sch. $25/$25 $10/$10 $10/$10 $10/$10 $10/$20 $15/$15 $15/$15 $15/$15 $15/$15 $15/$15 $15/$15 $15/$15 $15/$15 $15/$15 $10/$10 $250/day x 3 15%* 40%* None $240 $240 $240 None None $250/day x 3 None None None $500 $240 $100 None $240 $240 $240 None $250 $250 None $10 $10* $10* $5 $10 $10 $10 $10 N/A $10 $10 $10 $10 $10 $10 $10 $10 $5 $5 $5 $10 $10 $10 $5 $25/$40 $25*/$40* $25*/$40* $20/$35 $20/$35 $20/$35 $20/$35 $20/$50 N/A $25/$50 $20/$30 $20/$30 $15/$40 $20/$40 $25/$40 $25/$40 $20/$35 $20/$40 $20/$40 $20/$40 $20/$35 $20/$45 $20/$45 $10 Yes Yes* Yes* No Yes Yes Yes Yes No Yes Yes Yes Yes Yes No No No Yes Yes Yes Yes No No Yes * f * f Customer service * h h h h * * f f * * * * * h h h h * * * h h h h * * f f * * h h h h h h h h h h h h h h * * * * f f h h h h h h h h h * h h h h * * * * f f h h h h h h h * * * * h h h f f f f * * f f h h h h h * * h * See Brochure for details on patient’s payment responsibility. 53 Claims processing Brand Mail name/ order Generic Nondiscount formulary How well doctors communicate Primary care / Specialist office copay Hospital per stay deductible Prescription Drugs h above average, * average, f below average * h h h h * * f f f f * * h * * * h h h * Health Maintenance Organization (HMO) and Point of Service (POS) Plans How to read this chart: The table below highlights selected features that may help you narrow your choice of health plans. Always consult plan brochures before making your final decision. This chart does not show all of your possible out-of-pocket costs. Primary Care Specialist/Office Copay shows what you pay for each office visit to your primary care doctor and specialist. Contact your plan to find out what providers it considers specialists. Hospital per Stay Deductible is the amount you pay when you are admitted into a hospital. Plan Name – Location North Dakota Heart of America HMO - Northcentral North Dakota Telephone Number Self only Self & family Self only Self & family 800-525-5661 RU1 RU2 $13.32 $34.24 Ohio Aetna Health Inc. - Cleveland Area Aetna Health Inc. - Greater Cincinnati Area AultCare HMO - Stark/Carroll/Holmes/Tuscarawas/Wayne Co Blue HMO - Most of Ohio HMO Health Ohio - Northeast Ohio HOMETOWN HEALTH PLAN - Massillon Humana CoverageFirst (Consumer Driven Plan) - Cincinnati Kaiser Permanente - Cleveland/Akron areas Paramount Health Care - Northwest/North Central Ohio SummaCare Health Plan - Cleveland, Akron areas SuperMed HMO - Northeast Ohio The Health Plan of the Upper Ohio Valley - Eastern Ohio United Healthcare of Ohio, Inc. - Cincinnati/Dayton/Springfield areas 800/537-9384 800/537-9384 330/363-6360 800/228-4375 800/522-2066 800-426-9013 888/393-6765 800/686-7100 800/462-3589 330/996-8700 800/522-2066 800/624-6961 800/231-2918 7D1 RD1 3A1 R51 L41 MZ1 L81 641 U21 5W1 5M1 U41 3U1 7D2 RD2 3A2 R52 L42 MZ2 L82 642 U22 5W2 5M2 U42 3U2 $15.87 $16.99 $16.41 $30.39 $17.00 $14.59 $10.81 $17.08 $17.39 $16.36 $24.74 $17.38 $54.17 $38.23 $43.96 $40.29 $104.31 $59.53 $36.47 $24.86 $45.35 $82.11 $72.80 $102.77 $39.96 $127.11 NCQA 1 NCQA 1 NCQA 1 NCQA 1 NCQA 1 NCQA 1 NCQA 1 NCQA 1 NCQA 1 Oklahoma Aetna Health Inc. - Oklahoma City/Tulsa Areas PacifiCare Southwest Region (OK) - Central/Northeastern Oklahoma 800/537-9384 800-531-3341 SL1 2N1 SL2 2N2 $17.67 $18.82 $55.96 $63.67 NCQA 1 NCQA 1 Oregon Kaiser Permanente-High -Portland/Salem areas Kaiser Permanente-Std - Portland/Salem areas PacifiCare of Oregon - Metro Portland/Salem/Corvalis/Eugene 800/813-2000 800/813-2000 800-531-3341 571 574 7Z1 572 575 7Z2 $27.30 $16.84 $23.83 $64.45 $38.64 $48.98 NCQA 1 NCQA 1 NCQA 1 54 Accredited Enrollment Code Biweekly Premium Your Share Prescription Drugs — Generic, Brand Name, and Non-formulary shows what you pay for prescriptions when you use a plan pharmacy. You pay the Brand name amount if you or your doctor request the Brand name or if a Generic is not available. The figure in the Brand name/Non-formulary column is the copayment or coinsurance most commonly paid by members of this health plan for a Brand name formulary drug. If a nonformulary drug is prescribed and the cost to you is different than the Brand name, you pay the second amount if listed. Mail Order Discounts. If your plan has a Mail Order program and that program is superior to the purchase of medications at the pharmacy (e.g., you get a greater quantity or pay less through Mail Order), your plan’s response is “yes.” If the plan does not have a Mail Order program or it is not superior to its pharmacy benefit, the plan’s response is “no.” Member Survey Results — See page 3 for a description. Accredited — The National Committee for Quality Assurance (N); the Joint Commission on Accreditation of Healthcare Organizations (J); and/or URAC (U). See page 3 for details. A lower number means a better accreditation. Member Survey Results Getting needed care Overall plan satisfaction Getting care quickly Plan Name North Dakota Heart of America HMO $10/Nothing None 50% 50% No Ohio Aetna Health Inc. Aetna Health Inc. AultCare HMO Blue HMO HMO Health Ohio HOMETOWN HEALTH PLAN Humana CoverageFirst Kaiser Permanente Paramount Health Care SummaCare Health Plan SuperMed HMO The Health Plan of the Upper Ohio Valley United Healthcare of Ohio, Inc. - In-Network - Out-of-Network $20/$25 $20/$25 $10/$10 $10/$10 $10/$10 $15/$20 $20*/$35* 30%*/30%* $10/$10 $10/$20 $10/$10 $10/$10 $10/$20 $15/$15 $250/day x 3 $250/day x 3 None None None $250 $10 $10 $10 $10 $10 $15 $25/$40 $25/$40 $20/$35 $20/$30 $20/$30 $25/$40 Yes Yes No Yes Yes No No* No* No No Yes Yes Yes Yes h h * * * * * h h * h h * * h * h * * * h * h h * h * * h * * h h f h * * * h * * * * h h * h h h h * * * * h * * * h f * f f h * f $100/day x 5* $10/$25* $25/$50* 30%* $10/$25+30%*$25/$50+30%* $100 $300 None None $250 $250 $10 $5 $10 $10 $15 $10 $25 $15/$25 $20/$40 $20 $30/$50 $15/$30 Oklahoma Aetna Health Inc. PacifiCare Southwest Region (OK & TX) $20/$25 $20/$40 $250/day x 3 $400/day x 5 $10 $20 $25/$40 $40/$50 Yes Yes * f * * * * Oregon Kaiser Permanente-High Kaiser Permanente-Std PacifiCare of Oregon $10/$10 $15/$15 $20/$45 None None $400/day x 5 $10 $15 $20 $20 $30 $40/$50 Yes Yes Yes * * * * * * f f h f f h h h * * * * * See Brochure for details on patient’s payment responsibility. 55 Customer service Claims processing Brand Mail name/ order Generic Nondiscount formulary How well doctors communicate Primary care / Specialist office copay Hospital per stay deductible Prescription Drugs h above average, * average, f below average Health Maintenance Organization (HMO) and Point of Service (POS) Plans How to read this chart: The table below highlights selected features that may help you narrow your choice of health plans. Always consult plan brochures before making your final decision. This chart does not show all of your possible out-of-pocket costs. Primary Care Specialist/Office Copay shows what you pay for each office visit to your primary care doctor and specialist. Contact your plan to find out what providers it considers specialists. Hospital per Stay Deductible is the amount you pay when you are admitted into a hospital. Plan Name – Location Pennsylvania Aetna Health Inc. - Philadelphia and Southeastern PA Aetna Health Inc. - Pittsburgh Area Aetna HealthFund (Consumer Driven Plan) - Philadelphia and Southeastern PA HealthAmerica Pennsylvania-High -Greater Pittsburgh area HealthAmerica Pennsylvania-Std - Greater Pittsburgh area HealthAmerica Pennsylvania-High -Northeast Pennsylvania HealthAmerica Pennsylvania-Std - Northeast Pennsylvania HealthAmerica Pennsylvania-High -Central Pennsylvania HealthAmerica Pennsylvania-Std - Central Pennsylvania HealthAmerica Pennsylvania-High -Northwestern Pennsylvania HealthAmerica Pennsylvania-Std - Northwestern Pennsylvania Keystone Health Plan Central - Harrisburg/Northern Region/Lehigh Valley Keystone Health Plan East - Philadelphia area UPMC Health Plan - Western Pennsylvania area Telephone Number Self only Self & family Self only Self & family 800/537-9384 800/537-9384 888/238-6240 866/351-5946 866/351-5946 866/351-5946 866/351-5946 866/351-5946 866/351-5946 866/351-5946 866/351-5946 800/622-2843 800/227-3115 888/876-2756 P31 YE1 221 261 264 4N1 4N4 SW1 SW4 VJ1 VJ4 S41 ED1 8W1 P32 YE2 222 262 265 4N2 4N5 SW2 SW5 VJ2 VJ5 S42 ED2 8W2 $17.88 $13.95 $14.56 $20.91 $16.64 $35.82 $18.18 $33.88 $17.91 $16.82 $15.40 $30.89 $18.08 $17.56 $56.31 $38.47 $33.49 $91.67 $50.10 $117.14 $73.40 $102.05 $58.39 $54.22 $39.27 $91.05 $96.74 $71.09 NCQA 1 NCQA 1 NCQA 1 NCQA 1 NCQA 1 NCQA 1 NCQA 1 Puerto Rico Humana Health Plans of Puerto Rico - Puerto Rico Triple-S - All of Puerto Rico 800/314-3121 787/749-4777 ZJ1 891 ZJ2 892 $9.39 $12.70 $21.61 $27.29 Rhode Island Blue Chip, Coord Hlth Partners - All of Rhode Island 401/459-5500 DA1 DA2 $39.52 $141.05 NCQA 1 56 Accredited Enrollment Code Biweekly Premium Your Share Prescription Drugs — Generic, Brand Name, and Non-formulary shows what you pay for prescriptions when you use a plan pharmacy. You pay the Brand name amount if you or your doctor request the Brand name or if a Generic is not available. The figure in the Brand name/Non-formulary column is the copayment or coinsurance most commonly paid by members of this health plan for a Brand name formulary drug. If a nonformulary drug is prescribed and the cost to you is different than the Brand name, you pay the second amount if listed. Mail Order Discounts. If your plan has a Mail Order program and that program is superior to the purchase of medications at the pharmacy (e.g., you get a greater quantity or pay less through Mail Order), your plan’s response is “yes.” If the plan does not have a Mail Order program or it is not superior to its pharmacy benefit, the plan’s response is “no.” Member Survey Results — See page 3 for a description. Accredited — The National Committee for Quality Assurance (N); the Joint Commission on Accreditation of Healthcare Organizations (J); and/or URAC (U). See page 3 for details. A lower number means a better accreditation. Member Survey Results Getting needed care Overall plan satisfaction Getting care quickly Plan Name Pennsylvania Aetna Health Inc. Aetna Health Inc. Aetna HealthFund - In-Network - Out-of-Network $20/$25 $20/$25 15%*/15%* 40%*/40%* $10/$20 $20/$30 $10/$20 $20/$30 $10/$20 $20/$30 $10/$20 $20/$30 $15/$20 $10/$15 $10/$10 $250/day x 3 $250/day x 3 15%* 40%* None $200/day x 3 None $200/day x 3 None $200/day x 3 None $200/day x 3 None None None $10 $10 $10* $10* $10 $10 $10 $10 $10 $10 $10 $10 $10 $5 $5 $25/$40 $25/$40 $25*/$40* $25*/$40* $20/$40 $35/$60 $20/$40 $35/$60 $20/$40 $35/$60 $20/$40 $35/$60 $25/$40 $15/$25 $15/$35 Yes Yes Yes* Yes* Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes f * * * Customer service * HealthAmerica Pennsylvania-High HealthAmerica Pennsylvania-Std HealthAmerica Pennsylvania-High HealthAmerica Pennsylvania-Std HealthAmerica Pennsylvania-High HealthAmerica Pennsylvania-Std HealthAmerica Pennsylvania-High HealthAmerica Pennsylvania-Std Keystone Health Plan Central Keystone Health Plan East UPMC Health Plan f f h h h h h h * * f f h h h h h h * * h f * h * h h * * h * * * h * Puerto Rico Humana Health Plans of Puerto Rico Triple-S - In-Network - Out-of-Network - In-Network - Out-of-Network $5/$5 $8/$8 $7.50/$10 $7.50 + 10%/$10 + 10% None $50 None None $2.50 N/A $5 25% $5 N/A $8/$12 25% No No Yes No h h f h h * Rhode Island Blue Chip, Coord Hlth Partners - In-Network - Out-of-Network $15/$25 30%/30% $500 None $7 $40+20% $25/$40 $40+20% Yes No f h h h * * * See Brochure for details on patient’s payment responsibility. 57 Claims processing Brand Mail name/ order Generic Nondiscount formulary How well doctors communicate Primary care / Specialist office copay Hospital per stay deductible Prescription Drugs h above average, * average, f below average * f f f f h * * Health Maintenance Organization (HMO) and Point of Service (POS) Plans How to read this chart: The table below highlights selected features that may help you narrow your choice of health plans. Always consult plan brochures before making your final decision. This chart does not show all of your possible out-of-pocket costs. Primary Care Specialist/Office Copay shows what you pay for each office visit to your primary care doctor and specialist. Contact your plan to find out what providers it considers specialists. Hospital per Stay Deductible is the amount you pay when you are admitted into a hospital. Plan Name – Location South Dakota Avera Health Plans - Eastern and Central South Dakota Sioux Valley Health Plan-High -Eastern/Central/Rapid City Areas Sioux Valley Health Plan-Std - Eastern/Central/Rapid City Areas Telephone Number Self only Self & family Self only Self & family 888/322-2115 800/752-5863 800/752-5863 AV1 AU1 AU4 AV2 AU2 AU5 $16.29 $70.34 $38.00 $38.03 $164.13 $89.71 NCQA 2 NCQA 2 Tennessee Aetna Health Inc. - Nashville Area Aetna Health Inc. - Memphis Area Humana CoverageFirst (Consumer Driven Plan) - Memphis 800/537-9384 800/537-9384 888/393-6765 6J1 UB1 L61 6J2 UB2 L62 $15.57 $14.91 $10.81 $37.56 $39.90 $24.86 NCQA 1 NCQA 1 58 Accredited Enrollment Code Biweekly Premium Your Share Prescription Drugs — Generic, Brand Name, and Non-formulary shows what you pay for prescriptions when you use a plan pharmacy. You pay the Brand name amount if you or your doctor request the Brand name or if a Generic is not available. The figure in the Brand name/Non-formulary column is the copayment or coinsurance most commonly paid by members of this health plan for a Brand name formulary drug. If a nonformulary drug is prescribed and the cost to you is different than the Brand name, you pay the second amount if listed. Mail Order Discounts. If your plan has a Mail Order program and that program is superior to the purchase of medications at the pharmacy (e.g., you get a greater quantity or pay less through Mail Order), your plan’s response is “yes.” If the plan does not have a Mail Order program or it is not superior to its pharmacy benefit, the plan’s response is “no.” Member Survey Results — See page 3 for a description. Accredited — The National Committee for Quality Assurance (N); the Joint Commission on Accreditation of Healthcare Organizations (J); and/or URAC (U). See page 3 for details. A lower number means a better accreditation. Member Survey Results Getting needed care Overall plan satisfaction Getting care quickly Plan Name South Dakota Avera Health Plans Sioux Valley Health Plan Sioux Valley Health Plan - In-Network - Out-of-Network - In-Network - Out-of-Network $10/$15 $20/$30 40%/40% $25/$25 40%/40% $100/dayx3 $100/day x 5 40% $100/day x 5 40% $10 $15 N/A $15 N/A $20 $30/$50 N/A $30/$50 N/A No No No No No f f * * h h * * * * f f Tennessee Aetna Health Inc. Aetna Health Inc. Humana CoverageFirst - In-Network - Out-of-Network $20/$25 $20/$25 $20*/$35* 30%*/30%* $250/day x 3 $250/day x 3 $10 $10 $25/$40 $25/$40 Yes Yes No* No* * * * * * * * * h h f f $100/day x 5* $10/$25* $25/$50* 30%* $10/$25+30%*$25/$50+30%* * See Brochure for details on patient’s payment responsibility. 59 Customer service Claims processing Brand Mail name/ order Generic Nondiscount formulary How well doctors communicate Primary care / Specialist office copay Hospital per stay deductible Prescription Drugs h above average, * average, f below average Health Maintenance Organization (HMO) and Point of Service (POS) Plans How to read this chart: The table below highlights selected features that may help you narrow your choice of health plans. Always consult plan brochures before making your final decision. This chart does not show all of your possible out-of-pocket costs. Primary Care Specialist/Office Copay shows what you pay for each office visit to your primary care doctor and specialist. Contact your plan to find out what providers it considers specialists. Hospital per Stay Deductible is the amount you pay when you are admitted into a hospital. Plan Name – Location Texas Aetna Health Inc. - Austin/San Antonio Areas Aetna Health Inc. - Dallas/Ft Worth/Houston Areas FIRSTCARE - Waco area FIRSTCARE - West Texas HMO Blue Texas - Houston Humana CoverageFirst (Consumer Driven Plan) - Houston Humana CoverageFirst (Consumer Driven Plan) - Dallas/Ft. Worth Humana CoverageFirst (Consumer Driven Plan) - Corpus Christi Humana CoverageFirst (Consumer Driven Plan) - San Antonio Humana CoverageFirst (Consumer Driven Plan) - Austin Humana Health Plan of Texas-High -San Antonio area Humana Health Plan of Texas-Std - San Antonio area Mercy Health Plans/Premier Health Plans - Webb/Zapata/Duval/Jim Hogg Counties PacifiCare Southwest Region (TX) - San Antonio/Dallas/Ft.Worth Telephone Number Self only Self & family Self only Self & family 800/537-9384 800/537-9384 800/884-4901 800/884-4901 800/833-5318 888/393-6765 888/393-6765 888/393-6765 888/393-6765 888/393-6765 888/393-6765 888/393-6765 800/617-3433 800-531-3341 P11 PU1 6U1 CK1 YM1 T21 T81 TP1 TU1 TV1 UR1 UR4 HM1 GF1 P12 PU2 6U2 CK2 YM2 T22 T82 TP2 TU2 TV2 UR2 UR5 HM2 GF2 $14.38 $17.28 $16.86 $45.77 $17.41 $12.97 $12.43 $11.35 $10.81 $11.89 $27.30 $15.41 $30.79 $23.78 $36.22 $56.30 $36.21 $79.05 $51.81 $29.83 $28.59 $26.10 $24.86 $27.34 $65.32 $35.45 $108.17 $58.83 NCQA 1 NCQA 1 NCQA 2 NCQA 1 Utah Altius Health Plans - Wasatch Front 800/377-4161 9K1 9K2 $38.05 $71.90 Vermont MVP Health Care - All of Vermont 888/687-6277 VW1 VW2 $22.79 $101.86 NCQA 1 60 Accredited Enrollment Code Biweekly Premium Your Share Prescription Drugs — Generic, Brand Name, and Non-formulary shows what you pay for prescriptions when you use a plan pharmacy. You pay the Brand name amount if you or your doctor request the Brand name or if a Generic is not available. The figure in the Brand name/Non-formulary column is the copayment or coinsurance most commonly paid by members of this health plan for a Brand name formulary drug. If a nonformulary drug is prescribed and the cost to you is different than the Brand name, you pay the second amount if listed. Mail Order Discounts. If your plan has a Mail Order program and that program is superior to the purchase of medications at the pharmacy (e.g., you get a greater quantity or pay less through Mail Order), your plan’s response is “yes.” If the plan does not have a Mail Order program or it is not superior to its pharmacy benefit, the plan’s response is “no.” Member Survey Results — See page 3 for a description. Accredited — The National Committee for Quality Assurance (N); the Joint Commission on Accreditation of Healthcare Organizations (J); and/or URAC (U). See page 3 for details. A lower number means a better accreditation. Member Survey Results Getting needed care Overall plan satisfaction Getting care quickly Plan Name Texas Aetna Health Inc. Aetna Health Inc. FIRSTCARE FIRSTCARE HMO Blue Texas Humana CoverageFirst Humana CoverageFirst Humana CoverageFirst Humana CoverageFirst Humana CoverageFirst - In-Network - Out-of-Network - In-Network - Out-of-Network - In-Network - Out-of-Network - In-Network - Out-of-Network - In-Network - Out-of-Network $20/$25 $20/$25 $15/$25 $15/$25 $20/$20 $20*/$35* 30%*/30%* $20*/$35* 30%*/30%* $20*/$35* 30%*/30%* $20*/$35* 30%*/30%* $20*/$35* 30%*/30%* $10/$20 $15/$25 - In-Network - Out-of-Network $10/$10 40%/40% $20/$40 $250/day x 3 $250/day x 3 $100 $100 $100/dayx4 $10 $10 $10 $10 $10 $25/$40 $25/$40 $20/$40 $20/$40 $25/$40 Yes Yes Yes Yes Yes No* No* No* No* No* No* No* No* No* No* No No Yes No Yes * * h * * * * f f f f f * * h f h h h * * * h f * * f h h f h * f h h * * h f * h f $100/day x 5* $10/$25* $25/$50* 30%* $10/$25+30%*$25/$50+30%* $100/day x 5* $10/$25* $25/$50* 30%* $10/$25+30%*$25/$50+30%* $100/day x 5* $10/$25* $25/$50* 30%* $10/$25+30%*$25/$50+30%* $100/day x 5* $10/$25* $25/$50* 30%* $10/$25+30%*$25/$50+30%* $100/day x 5* $10/$25* $25/$50* 30%* $10/$25+30%*$25/$50+30%* $100/day x 3 $250/day x 3 None None $400/day x 5 $5/$20 $10/$25 $7 N/A $20 $20/$40 $25/$45 $12/$25 N/A $40/$50 Humana Health Plan of Texas-High Humana Health Plan of Texa-Std Mercy Health Plans/Premier PacifiCare Southwest Region (OK & TX) Utah Altius Health Plans $10/$15 None $10 $20/$40 Yes f * f f f f Vermont MVP Health Care $15/$15 $240 $5 $20/$40 Yes h h h h h * * See Brochure for details on patient’s payment responsibility. 61 Customer service Claims processing Brand Mail name/ order Generic Nondiscount formulary How well doctors communicate Primary care / Specialist office copay Hospital per stay deductible Prescription Drugs h above average, * average, f below average Health Maintenance Organization (HMO) and Point of Service (POS) Plans How to read this chart: The table below highlights selected features that may help you narrow your choice of health plans. Always consult plan brochures before making your final decision. This chart does not show all of your possible out-of-pocket costs. Primary Care Specialist/Office Copay shows what you pay for each office visit to your primary care doctor and specialist. Contact your plan to find out what providers it considers specialists. Hospital per Stay Deductible is the amount you pay when you are admitted into a hospital. Plan Name – Location Virginia Aetna Health Inc.-High -Northern/Central/Richmond, Virginia Area Aetna Health Inc.-Std - Northern/Central/Richmond, Virginia Area Aetna HealthFund (Consumer Driven Plan) - Northern/Central/Richmond VA Areas CareFirst BlueChoice - Northern Virginia Kaiser Permanente - Washington, DC area M.D. IPA - N.VA/Cntrl VA/Richmond/Tidewater/Roanoke Optima Health Plan - Peninsula/Southside Hampton Roads Piedmont Community Healthcare - Lynchburg area Telephone Number Self only Self & family Self only Self & family 800/537-9384 800/537-9384 888/238-6240 866/520-6099 301/468-6000 800/251-0956 800/206-1060 888/674-3368 JN1 JN4 221 2G1 E31 JP1 9R1 2C1 JN2 JN5 222 2G2 E32 JP2 9R2 2C2 $18.11 $11.90 $14.56 $38.32 $16.42 $16.52 $23.43 $18.83 $40.78 $27.84 $33.49 $81.51 $39.09 $39.64 $67.46 $44.18 NCQA 1 NCQA 1 NCQA 2 NCQA 2 NCQA 1 NCQA 1 Washington Aetna Health Inc. - Western/Southeast Washington Aetna HealthFund (Consumer Driven Plan) - Seattle/Western Washington Group Health Cooperative-High -Most of Western Washington Group Health Cooperative-Std - Most of Western Washington Group Health Cooperative-High -Central WA/Spokane/Pullman Group Health Cooperative-Std - Central WA/Spokane/Pullman Kaiser Permanente-High -Vancouver/Longview Kaiser Permanente-Std - Vancouver/Longview KPS Health Plans - High -All of Western Washington KPS Health Plans - Std - All of Western Washington PacifiCare of Oregon - Clark County 800/537-9384 888/238-6240 888/901-4636 888/901-4636 888/901-4636 888/901-4636 800/813-2000 800/813-2000 800/552-7114 800/552-7114 800-531-3341 8J1 221 541 544 VR1 VR4 571 574 VT1 L11 7Z1 8J2 222 542 545 VR2 VR5 572 575 VT2 L12 7Z2 $13.38 $14.56 $26.20 $15.96 $17.91 $15.52 $27.30 $16.84 $35.55 $16.20 $23.83 $34.02 $33.49 $55.56 $36.04 $61.10 $35.71 $64.45 $38.64 $63.72 $35.40 $48.98 NCQA 1 NCQA 1 NCQA 1 NCQA 1 NCQA 1 NCQA 1 NCQA 1 62 Accredited Enrollment Code Biweekly Premium Your Share Prescription Drugs — Generic, Brand Name, and Non-formulary shows what you pay for prescriptions when you use a plan pharmacy. You pay the Brand name amount if you or your doctor request the Brand name or if a Generic is not available. The figure in the Brand name/Non-formulary column is the copayment or coinsurance most commonly paid by members of this health plan for a Brand name formulary drug. If a nonformulary drug is prescribed and the cost to you is different than the Brand name, you pay the second amount if listed. Mail Order Discounts. If your plan has a Mail Order program and that program is superior to the purchase of medications at the pharmacy (e.g., you get a greater quantity or pay less through Mail Order), your plan’s response is “yes.” If the plan does not have a Mail Order program or it is not superior to its pharmacy benefit, the plan’s response is “no.” Member Survey Results — See page 3 for a description. Accredited — The National Committee for Quality Assurance (N); the Joint Commission on Accreditation of Healthcare Organizations (J); and/or URAC (U). See page 3 for details. A lower number means a better accreditation. Member Survey Results Getting needed care Overall plan satisfaction Getting care quickly Plan Name Virginia Aetna Health Inc.-High Aetna Health Inc.-Std Aetna HealthFund CareFirst BlueChoice Kaiser Permanente M.D. IPA Optima Health Plan Piedmont Community Healthcare - In-Network - Out-of-Network - In-Network - Out-of-Network $15/$20 $20/$25 15%*/15%* 40%*/40%* $20/$30 $10/$20 $10/$20 $10/$20 $25/$25 40%/30% $150/day x 3 $250/day x 3 15%* 40%* $100/day x 5 $100 $100 $250 None None $10 $10 $10* $10* $10 $10/$20Net $8 $10 $15 $15 $25/$40 $25/$40 $25*/$40* $25*/$40* $25/$40 $20/$40 $20/$35 $20/$40 $30 $30 No No Yes* Yes* Yes Yes No Yes Yes No f f * * f f * * Customer service * * f * * h f f * h f f * * * f * * f * h h Washington Aetna Health Inc. Aetna HealthFund Group Health Cooperative-High Group Health Cooperative-Std Group Health Cooperative-High Group Health Cooperative-Std Kaiser Permanente-High Kaiser Permanente-Std KPS Health Plans KPS Health Plans PacifiCare of Oregon - In-Network - Out-of-Network - In-Network - Out-of-Network - In-Network - Out-of-Network $20/$25 15%*/15%* 40%*/40%* $15/$15 $20+20%/$20+20% $15/$15 $20+20%/$20+20% $10/$10 $15/$15 $15/$25 $15+45%/$25+45% $15/x3 or 20%/20% $15/x3 or 45%/45% $20/$45 $250/day x 3 15%* 40%* $200/day x 3 $200/day x 3 $200/day x 3 $200/day x 3 None None None None $100/day x 5 $100/day x 5 $400/day x 5 $10 $10* $10* $15 $20 $15 $20 $10 $15 $5 N/A $10 N/A $20 $25/$40 $25*/$40* $25*/$40* $25/$50 $30/$60 $25/$50 $30/$60 $20 $30 $20/50% N/A $30/50% N/A $40/$50 Yes Yes* Yes* Yes Yes Yes Yes Yes Yes Yes No Yes No Yes * * * * * * h * * * * * * h h h h h f f h * * * * f f h * * * * h h h * * * * * * h f * * * f f * See Brochure for details on patient’s payment responsibility. 63 Claims processing Brand Mail name/ order Generic Nondiscount formulary How well doctors communicate Primary care / Specialist office copay Hospital per stay deductible Prescription Drugs h above average, * average, f below average * * f * h h Health Maintenance Organization (HMO) and Point of Service (POS) Plans How to read this chart: The table below highlights selected features that may help you narrow your choice of health plans. Always consult plan brochures before making your final decision. This chart does not show all of your possible out-of-pocket costs. Primary Care Specialist/Office Copay shows what you pay for each office visit to your primary care doctor and specialist. Contact your plan to find out what providers it considers specialists. Hospital per Stay Deductible is the amount you pay when you are admitted into a hospital. Plan Name – Location West Virginia The Health Plan of the Upper Ohio Valley - Northern/Central West Virginia Telephone Number Self only Self & family Self only Self & family 800/624-6961 U41 U42 $17.38 $39.96 NCQA 1 Wisconsin Dean Health Plan - South Central Wisconsin Group Health Cooperative - South Central Wisconsin HealthPartners Classic-High -West Central Wisconsin HealthPartners Open Access-Basic - West Central Wisconsin HealthPartners Primary Clinic Plan - West Central Wisconsin Humana CoverageFirst (Consumer Driven Plan) - Milwaukee 800/279-1301 608/251-3356 952-883-5000 952-883-5000 952-883-5000 888/393-6765 WD1 WJ1 531 534 HQ1 FB1 WD2 WJ2 532 535 HQ2 FB2 $15.23 $14.90 $50.11 $20.64 $96.57 $11.89 $41.11 $40.27 $137.10 $66.36 $248.60 $27.34 NCQA 1 NCQA 1 NCQA 1 NCQA 1 NCQA 1 Wyoming WINhealth Partners - Wyoming 307/638-7700 PV1 PV2 $27.94 $135.26 64 Accredited Enrollment Code Biweekly Premium Your Share Prescription Drugs — Generic, Brand Name, and Non-formulary shows what you pay for prescriptions when you use a plan pharmacy. You pay the Brand name amount if you or your doctor request the Brand name or if a Generic is not available. The figure in the Brand name/Non-formulary column is the copayment or coinsurance most commonly paid by members of this health plan for a Brand name formulary drug. If a nonformulary drug is prescribed and the cost to you is different than the Brand name, you pay the second amount if listed. Mail Order Discounts. If your plan has a Mail Order program and that program is superior to the purchase of medications at the pharmacy (e.g., you get a greater quantity or pay less through Mail Order), your plan’s response is “yes.” If the plan does not have a Mail Order program or it is not superior to its pharmacy benefit, the plan’s response is “no.” Member Survey Results — See page 3 for a description. Accredited — The National Committee for Quality Assurance (N); the Joint Commission on Accreditation of Healthcare Organizations (J); and/or URAC (U). See page 3 for details. A lower number means a better accreditation. Member Survey Results Getting needed care Overall plan satisfaction Getting care quickly Plan Name West Virginia The Health Plan of the Upper Ohio Valley $10/$20 $250 $15 $30/$50 Yes * h h h Customer service h Wisconsin Dean Health Plan Group Health Cooperative HealthPartners Classic-High HealthPartners Open Access-Basic HealthPartners Primary Clinic Plan Humana CoverageFirst - In-Network - Out-of-Network $10/$10 $20/$20 $15/$15 $15/$15 $20/$20 $20*/$35* 30%*/30%* None None $100 $100 $200 $10 $6 $12 $10 $12 30% $12 $12/$24 $10/$35 $12/$24 No No No No No No* No* h * f f f h * * * * h h * * * * * * * * * * f f f h h * * * $100/day x 5* $10/$25* $25/$50* 30%* $10/$25+30%*$25/$50+30%* Wyoming WINhealth Partners $10/$10 None $10 $15/$40 Yes * See Brochure for details on patient’s payment responsibility. 65 Claims processing Brand Mail name/ order Generic Nondiscount formulary How well doctors communicate Primary care / Specialist office copay Hospital per stay deductible Prescription Drugs h above average, * average, f below average h